- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $12,882.50 / $12,882.50
| Facility | | $8,128.31 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $8,128.31
| Professional | | $1,862.09 | $2,630.27 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $4,168.69
| Facility | | $2,570.40 | $3,715.35 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $2,454.71
| Professional | | $1,819.70 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,709.64 / $8,912.51
| Facility | | $4,897.79 | $8,709.64 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $9,120.11
| Professional | | $1,621.81 | $1,949.84 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $4,073.80
| Professional | | $1,348.96 | $1,949.84 | $4,073.80 |