- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $25,703.96
| Facility | | $9,332.54 | $9,332.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $3,715.35
| Professional | | $1,995.26 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,079.46 / $21,379.62
| Facility | | $6,309.57 | $7,079.46 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $3,467.37
| Professional | | $1,513.56 | $2,398.83 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $11,481.54 / $16,218.10
| Facility | | $6,025.60 | $11,481.54 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $7,079.46
| Professional | | $3,715.35 | $3,715.35 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $3,890.45
| Professional | | $2,187.76 | $2,187.76 | $3,890.45 |