- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,908.90 / $11,752.40 / $20,699.40
| Facility | | $6,908.90 | $11,752.40 | $20,699.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $2,666.54
| Professional | | $2,666.54 | $2,666.54 | $2,666.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.81 / $11,126.88 / $29,570.58
| Facility | | $1,404.81 | $11,126.88 | $29,570.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.27 / $981.67 / $6,173.47
| Professional | | $846.27 | $981.67 | $6,173.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,766.73 / $12,813.92 / $22,744.70
| Facility | | $6,766.73 | $12,813.92 | $22,744.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,098.64 / $9,235.41 / $11,065.06
| Professional | | $9,098.64 | $9,235.41 | $11,065.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,098.64 / $9,098.64 / $9,098.64
| Facility | | $9,098.64 | $9,098.64 | $9,098.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $10,013.81
| Professional | | $3,184.52 | $4,549.32 | $10,013.81 |