- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,456.54 / $8,128.31
| Facility | | $5,495.41 | $6,456.54 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,265.80 / $6,456.54
| Professional | | $2,951.21 | $4,265.80 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $70.79 / $95.50
| Facility | | $58.88 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $3,548.13
| Professional | | $426.58 | $602.56 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $11,748.98
| Facility | | $3,548.13 | $4,466.84 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,897.79 / $5,495.41
| Facility | | $2,290.87 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,311.31
| Professional | | $2,290.87 | $2,290.87 | $3,311.31 |