- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,717.53 / $5,256.68 / $31,960.60
| Facility | | $4,717.53 | $5,256.68 | $31,960.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,256.68 / $5,256.68 / $5,863.22
| Professional | | $5,256.68 | $5,256.68 | $5,863.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,739.33 / $6,739.33 / $9,216.03
| Professional | | $6,739.33 | $6,739.33 | $9,216.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,490.74 / $13,667.35 / $38,426.26
| Facility | | $4,490.74 | $13,667.35 | $38,426.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,189.28 / $6,739.33 / $7,211.08
| Facility | | $5,189.28 | $6,739.33 | $7,211.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $3,843.98 / $6,136.90
| Professional | | $2,830.52 | $3,843.98 | $6,136.90 |