- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,749.93 / $10,796.10 / $16,682.09
| Facility | | $5,749.93 | $10,796.10 | $16,682.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,918.45 / $4,545.39 / $5,224.60
| Professional | | $3,918.45 | $4,545.39 | $5,224.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,530.75 / $6,530.75 / $6,530.75
| Professional | | $6,530.75 | $6,530.75 | $6,530.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,618.55 / $8,557.89 / $11,847.07
| Facility | | $4,618.55 | $8,557.89 | $11,847.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,179.68 / $5,224.60 / $7,028.71
| Facility | | $4,179.68 | $5,224.60 | $7,028.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $26,018.51
| Professional | | $2,194.33 | $3,134.76 | $26,018.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,134.76 / $3,134.76 / $5,224.60
| Facility | | $3,134.76 | $3,134.76 | $5,224.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $7,836.90
| Professional | | $2,194.33 | $3,134.76 | $7,836.90 |