- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.19 / $1,117.19 / $2,446.69
| Professional | | $1,117.19 | $1,117.19 | $2,446.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,418.01 / $9,442.60 / $11,134.41
| Facility | | $8,418.01 | $9,442.60 | $11,134.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.45 / $3,513.47 / $3,513.47
| Professional | | $2,986.45 | $3,513.47 | $3,513.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.94 / $2,307.57 / $4,726.32
| Professional | | $2,015.94 | $2,307.57 | $4,726.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.40 / $2,072.71 / $5,547.77
| Professional | | $1,860.40 | $2,072.71 | $5,547.77 |