- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $26,915.35
| Facility | | $9,772.37 | $9,772.37 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $3,388.44
| Professional | | $2,089.30 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $7,413.10 / $22,387.21
| Facility | | $6,606.93 | $7,413.10 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,511.89 / $2,511.89
| Professional | | $1,258.93 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $12,022.64 / $16,982.44
| Facility | | $6,309.57 | $12,022.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $7,413.10
| Professional | | $3,890.45 | $3,890.45 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $4,073.80
| Professional | | $2,344.23 | $2,344.23 | $4,073.80 |