- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $9,332.54 / $18,620.87
| Facility | | $4,897.79 | $9,332.54 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $5,011.87
| Professional | | $3,311.31 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Professional | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,120.11 / $11,220.18
| Facility | | $4,466.84 | $9,120.11 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,011.87 / $6,760.83
| Facility | | $3,981.07 | $5,011.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $25,118.86
| Professional | | $2,089.30 | $3,019.95 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,011.87 / $6,025.60
| Facility | | $2,089.30 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $6,456.54
| Professional | | $2,089.30 | $3,019.95 | $6,456.54 |