- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,332.54 / $13,803.84
| Facility | | $4,570.88 | $9,332.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $5,128.61
| Professional | | $1,659.59 | $2,187.76 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,302.68 / $47,863.01 / $67,608.30
| Facility | | $26,302.68 | $47,863.01 | $67,608.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $3,388.44
| Professional | | $1,023.29 | $1,479.11 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,772.37 / $25,118.86
| Facility | | $4,570.88 | $9,772.37 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $3,467.37
| Professional | | $1,047.13 | $1,862.09 | $3,467.37 |