- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $14,125.38 / $26,915.35
| Facility | | $4,265.80 | $14,125.38 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $6,606.93
| Professional | | $1,318.26 | $1,778.28 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $9,332.54
| Facility | | $1,412.54 | $2,290.87 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,981.07 / $9,772.37
| Professional | | $3,090.30 | $3,981.07 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $8,709.64
| Professional | | $5,623.41 | $5,623.41 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,606.93 / $9,332.54
| Facility | | $2,290.87 | $6,606.93 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,348.96 / $4,786.30
| Professional | | $60.26 | $1,348.96 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,890.45 / $8,912.51
| Professional | | $3,548.13 | $3,890.45 | $8,912.51 |