- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,912.51 / $8,912.51
| Facility | | $8,128.31 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $2,089.30 / $3,235.94
| Professional | | $14.13 | $2,089.30 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $5,888.44
| Professional | | $4,168.69 | $4,168.69 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,388.44 / $7,943.28
| Facility | | $1,819.70 | $3,388.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,951.21 / $2,951.21
| Professional | | $2,884.03 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,621.81
| Professional | | $1,148.15 | $1,148.15 | $1,621.81 |