- 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
- $1,778.28 / $1,778.28 / $2,884.03
| Professional | | $1,778.28 | $1,778.28 | $2,884.03 |
- 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 / $3,467.37 / $6,606.93
| Professional | | $3,467.37 | $3,467.37 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,715.35
| Professional | | $2,089.30 | $2,089.30 | $3,715.35 |