- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $24,547.09
| Facility | | $8,912.51 | $8,912.51 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $3,019.95
| Professional | | $2,454.71 | $2,818.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,760.83 / $19,952.62
| Facility | | $6,025.60 | $6,760.83 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $2,290.87 / $3,311.31
| Professional | | $239.88 | $2,290.87 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $10,964.78 / $15,488.17
| Facility | | $5,623.41 | $10,964.78 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,623.41 / $9,120.11
| Professional | | $3,467.37 | $5,623.41 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $5,370.32
| Professional | | $2,089.30 | $2,089.30 | $5,370.32 |