- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $29,512.09
| Facility | | $3,548.13 | $3,548.13 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,630.78 / $3,890.45
| Professional | | $3,311.31 | $3,630.78 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $4,168.69
| Professional | | $3,467.37 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $8,128.31 / $18,197.01
| Facility | | $7,762.47 | $8,128.31 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,317.64 / $9,772.37
| Professional | | $5,495.41 | $8,317.64 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $6,025.60
| Professional | | $1,995.26 | $2,137.96 | $6,025.60 |