- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,348.98 / $10,649.58 / $25,619.01
| Facility | | $6,348.98 | $10,649.58 | $25,619.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,719.13 / $4,676.53 / $6,488.26
| Professional | | $3,719.13 | $4,676.53 | $6,488.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,820.36 / $9,736.27 / $20,172.45
| Facility | | $5,820.36 | $9,736.27 | $20,172.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,682.31 / $3,682.31 / $5,820.36
| Professional | | $3,682.31 | $3,682.31 | $5,820.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,339.22 / $5,339.22 / $11,678.40
| Facility | | $5,339.22 | $5,339.22 | $11,678.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,678.40 / $11,678.40 / $11,678.40
| Professional | | $11,678.40 | $11,678.40 | $11,678.40 |