- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $26,915.35 / $39,810.72
| Facility | | $5,888.44 | $26,915.35 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,309.57 / $9,332.54
| Professional | | $5,888.44 | $6,309.57 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $9,120.11 / $11,748.98
| Professional | | $8,511.38 | $9,120.11 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $21,379.62 / $47,863.01
| Facility | | $5,495.41 | $21,379.62 | $47,863.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,585.78 / $15,488.17
| Facility | | $6,309.57 | $7,585.78 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $8,511.38 / $10,232.93
| Facility | | $7,585.78 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $4,265.80
| Professional | | $1,548.82 | $2,187.76 | $4,265.80 |