- 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
- $974.76 / $974.76 / $2,241.15
| Professional | | $974.76 | $974.76 | $2,241.15 |
- 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
- $3,080.73 / $3,624.39 / $3,624.39
| Professional | | $3,080.73 | $3,624.39 | $3,624.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.01 / $1,995.18 / $4,329.33
| Professional | | $1,743.01 | $1,995.18 | $4,329.33 |
- 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
- $1,622.64 / $3,454.53 / $5,722.90
| Professional | | $1,622.64 | $3,454.53 | $5,722.90 |