- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,317.64 / $15,848.93
| Facility | | $4,570.88 | $8,317.64 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,467.37 / $4,365.16
| Professional | | $2,511.89 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $281.84 / $831.76
| Professional | | $128.82 | $281.84 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $50,118.72
| Facility | | $8,511.38 | $8,511.38 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,819.70
| Professional | | $758.58 | $977.24 | $1,819.70 |