- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $28,183.83 / $28,183.83
| Facility | | $12,589.25 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,918.31 / $10,715.19
| Professional | | $5,888.44 | $6,918.31 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $18,197.01
| Professional | | $13,182.57 | $13,182.57 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $10,715.19 / $25,118.86
| Facility | | $5,623.41 | $10,715.19 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $9,332.54 / $12,302.69
| Professional | | $8,912.51 | $9,332.54 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,187.76
| Professional | | $1,548.82 | $1,548.82 | $2,187.76 |