- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $11,481.54
| Facility | | $5,248.07 | $5,248.07 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $5,248.07
| Professional | | $2,754.23 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,709.64 / $14,125.38
| Facility | | $6,456.54 | $8,709.64 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,786.30 / $6,606.93
| Professional | | $2,344.23 | $4,786.30 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $8,511.38 / $30,199.52
| Facility | | $3,388.44 | $8,511.38 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $11,220.18
| Professional | | $5,495.41 | $9,549.93 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $9,120.11
| Professional | | $2,511.89 | $3,162.28 | $9,120.11 |