- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $16,595.87 / $16,595.87
| Facility | | $7,585.78 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $6,025.60
| Professional | | $3,715.35 | $4,677.35 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $10,715.19
| Professional | | $7,762.47 | $7,762.47 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,309.57 / $14,791.08
| Facility | | $3,388.44 | $6,309.57 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,495.41 / $7,244.36
| Professional | | $5,248.07 | $5,495.41 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,019.95
| Professional | | $2,089.30 | $2,089.30 | $3,019.95 |