- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,754.40 / $6,309.57
| Facility | | $4,897.79 | $5,754.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $1,819.70 / $8,128.31
| Professional | | $177.83 | $1,819.70 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Professional | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,897.79 / $6,309.57
| Facility | | $1,047.13 | $4,897.79 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,148.15 / $3,715.35
| Professional | | $660.69 | $1,148.15 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,244.36 / $12,882.50
| Facility | | $3,467.37 | $7,244.36 | $12,882.50 |