- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $19,498.45 / $19,498.45
| Facility | | $2,344.23 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $2,344.23 / $2,570.40
| Professional | | $478.63 | $2,344.23 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $2,754.23
| Professional | | $2,290.87 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,370.32 / $12,022.64
| Facility | | $5,128.61 | $5,370.32 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $6,456.54
| Professional | | $3,630.78 | $3,630.78 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,412.54 / $3,981.07
| Professional | | $1,318.26 | $1,412.54 | $3,981.07 |