- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,456.54 / $12,882.50
| Facility | | $3,162.28 | $6,456.54 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,025.60 / $8,128.31
| Professional | | $3,801.89 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $4,265.80 / $8,912.51
| Facility | | $54.95 | $4,265.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $37,153.52
| Professional | | $4,265.80 | $5,370.32 | $37,153.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,370.32 / $8,511.38
| Professional | | $4,073.80 | $5,370.32 | $8,511.38 |