- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $46,773.51
| Facility | | $5,623.41 | $5,623.41 | $46,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,623.41 / $6,165.95
| Professional | | $2,691.53 | $5,623.41 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $6,606.93
| Professional | | $5,495.41 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,882.50 / $28,840.32
| Facility | | $12,302.69 | $12,882.50 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $15,488.17
| Professional | | $8,709.64 | $8,709.64 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,388.44 / $9,549.93
| Professional | | $3,162.28 | $3,388.44 | $9,549.93 |