- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,762.47
| Facility | | $1,698.24 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,073.80 / $11,481.54
| Professional | | $3,630.78 | $4,073.80 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $15,488.17 / $31,622.78
| Professional | | $4,466.84 | $15,488.17 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,309.57 / $10,715.19
| Professional | | $3,890.45 | $6,309.57 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $8,128.31 / $8,912.51
| Professional | | $3,630.78 | $8,128.31 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $87,096.36
| Facility | | $9,120.11 | $25,703.96 | $87,096.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,248.07 / $10,715.19
| Professional | | $3,388.44 | $5,248.07 | $10,715.19 |