- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,370.32 / $10,715.19
| Facility | | $3,090.30 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,905.46
| Professional | | $1,862.09 | $1,862.09 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $15,135.61 / $28,183.83
| Facility | | $7,762.47 | $15,135.61 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $4,677.35
| Professional | | $2,630.27 | $3,311.31 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $5,248.07
| Professional | | $602.56 | $602.56 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,760.83 / $12,882.50
| Facility | | $2,630.27 | $6,760.83 | $12,882.50 |