- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $16,595.87
| Facility | | $6,760.83 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,495.41 / $9,772.37
| Professional | | $4,265.80 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,025.60 / $9,120.11
| Professional | | $4,466.84 | $6,025.60 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,606.93 / $11,481.54
| Facility | | $4,466.84 | $6,606.93 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,754.40 / $10,964.78
| Professional | | $4,168.69 | $5,754.40 | $10,964.78 |