- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $10,471.29 / $10,471.29
| Facility | | $9,549.93 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $2,344.23 / $3,630.78
| Professional | | $478.63 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,760.83
| Professional | | $4,897.79 | $4,897.79 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $3,801.89 / $9,332.54
| Facility | | $478.63 | $3,801.89 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,467.37 / $4,570.88
| Professional | | $3,311.31 | $3,467.37 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,905.46
| Professional | | $1,318.26 | $1,318.26 | $1,905.46 |