- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,176.41 / $5,176.41 / $5,176.41
| Facility | | $5,176.41 | $5,176.41 | $5,176.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,226.82 / $7,066.22 / $20,305.30
| Professional | | $4,226.82 | $7,066.22 | $20,305.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $8,923.48
| Professional | | $3,429.16 | $3,429.16 | $8,923.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,506.80 / $9,383.51 / $14,075.26
| Professional | | $7,506.80 | $9,383.51 | $14,075.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,266.64 / $2,266.64 / $7,051.76
| Facility | | $2,266.64 | $2,266.64 | $7,051.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $4,697.47 / $8,794.54
| Professional | | $3,429.16 | $4,697.47 | $8,794.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,246.20 / $3,511.00 / $5,372.77
| Professional | | $3,246.20 | $3,511.00 | $5,372.77 |