- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $12,022.64
| Facility | | $5,495.41 | $5,495.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,981.07 / $5,495.41
| Professional | | $2,951.21 | $3,981.07 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $14,791.08
| Facility | | $6,760.83 | $9,120.11 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,265.80 / $5,754.40
| Professional | | $2,818.38 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $31,622.78
| Facility | | $3,548.13 | $3,548.13 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,232.93 / $11,748.98
| Professional | | $7,413.10 | $10,232.93 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $9,549.93
| Professional | | $2,630.27 | $3,311.31 | $9,549.93 |