- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.22 / $4,075.19 / $24,777.20
| Facility | | $3,657.22 | $4,075.19 | $24,777.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,075.19 / $4,075.19 / $4,545.39
| Professional | | $4,075.19 | $4,075.19 | $4,545.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.22 / $621.22 / $621.22
| Facility | | $621.22 | $621.22 | $621.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,224.60 / $5,485.83 / $7,209.95
| Professional | | $5,224.60 | $5,485.83 | $7,209.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,495.19 / $12,870.80 / $29,789.62
| Facility | | $9,495.19 | $12,870.80 | $29,789.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,075.19 / $5,224.60 / $6,601.81
| Facility | | $4,075.19 | $5,224.60 | $6,601.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,702.14 / $4,702.14 / $6,269.52
| Facility | | $4,702.14 | $4,702.14 | $6,269.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $2,873.53 / $5,224.60
| Professional | | $2,194.33 | $2,873.53 | $5,224.60 |