- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,128.31 / $11,748.98
| Facility | | $4,570.88 | $8,128.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $4,677.35
| Professional | | $1,230.27 | $1,778.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,877.62 / $33,884.42 / $52,480.75
| Facility | | $21,877.62 | $33,884.42 | $52,480.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $4,897.79
| Professional | | $1,513.56 | $2,187.76 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,772.37 / $25,118.86
| Facility | | $4,570.88 | $9,772.37 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,090.30 / $5,623.41
| Professional | | $1,737.80 | $3,090.30 | $5,623.41 |