- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $26,915.35
| Facility | | $9,772.37 | $9,772.37 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $3,388.44
| Professional | | $2,089.30 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $7,413.10 / $22,387.21
| Facility | | $6,760.83 | $7,413.10 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $2,511.89 / $3,630.78
| Professional | | $239.88 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $8,912.51 / $14,125.38
| Facility | | $2,511.89 | $8,912.51 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $7,413.10
| Professional | | $3,890.45 | $3,890.45 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,890.45
| Professional | | $2,344.23 | $2,344.23 | $3,890.45 |