- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $30,902.95
| Facility | | $3,715.35 | $3,715.35 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $4,073.80
| Professional | | $3,467.37 | $3,801.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,981.07 / $4,365.16
| Professional | | $3,630.78 | $3,981.07 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,511.38 / $19,054.61
| Facility | | $8,128.31 | $8,511.38 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $10,232.93
| Professional | | $5,754.40 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $6,309.57
| Professional | | $2,089.30 | $2,238.72 | $6,309.57 |