- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $23,988.33
| Facility | | $8,709.64 | $8,709.64 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $3,019.95
| Professional | | $1,862.09 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,606.93 / $19,952.62
| Facility | | $5,888.44 | $6,606.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $2,238.72 / $3,235.94
| Professional | | $323.59 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $7,762.47 / $12,589.25
| Facility | | $2,238.72 | $7,762.47 | $12,589.25 |
- 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
- $2,041.74 / $2,041.74 / $3,467.37
| Professional | | $2,041.74 | $2,041.74 | $3,467.37 |