- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,978.39 / $2,978.39 / $2,978.39
| Facility | | $2,978.39 | $2,978.39 | $2,978.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,978.39 / $3,308.81 / $29,466.60
| Professional | | $2,978.39 | $3,308.81 | $29,466.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $7,261.93
| Facility | | $7,261.93 | $7,261.93 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $12,650.25
| Professional | | $5,301.21 | $5,301.21 | $12,650.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,753.17 / $7,666.41 / $9,966.33
| Professional | | $4,753.17 | $7,666.41 | $9,966.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,195.54 / $10,255.44 / $10,255.44
| Facility | | $9,195.54 | $10,255.44 | $10,255.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,839.81 / $7,351.10 / $11,026.65
| Professional | | $5,839.81 | $7,351.10 | $11,026.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.55 / $4,613.50 / $6,602.10
| Professional | | $4,265.55 | $4,613.50 | $6,602.10 |