- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $19,054.61
| Facility | | $6,918.31 | $6,918.31 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $2,238.72
| Professional | | $457.09 | $457.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $15,848.93
| Facility | | $4,786.30 | $5,248.07 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,778.28 / $2,570.40
| Professional | | $208.93 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,709.64 / $12,022.64
| Facility | | $4,466.84 | $8,709.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $5,248.07
| Professional | | $2,754.23 | $2,754.23 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,884.03
| Professional | | $1,659.59 | $1,659.59 | $2,884.03 |