- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $10,715.19 / $19,498.45
| Facility | | $5,011.87 | $10,715.19 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $5,248.07
| Professional | | $3,467.37 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $9,549.93 / $11,748.98
| Facility | | $4,677.35 | $9,549.93 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,248.07 / $7,079.46
| Facility | | $4,168.69 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $26,302.68
| Professional | | $2,187.76 | $3,162.28 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,248.07 / $6,309.57
| Facility | | $2,187.76 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $6,760.83
| Professional | | $2,187.76 | $3,162.28 | $6,760.83 |