- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,128.31 / $13,489.63
| Facility | | $5,011.87 | $8,128.31 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $58.88 / $70.79
| Professional | | $50.12 | $58.88 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $10,715.19
| Facility | | $7,079.46 | $7,079.46 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,162.28 / $3,162.28
| Professional | | $1,318.26 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $10,232.93 / $11,220.18
| Facility | | $9,549.93 | $10,232.93 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,819.70 / $1,819.70
| Professional | | $912.01 | $1,819.70 | $1,819.70 |