- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $5,208.93 / $7,920.26
| Facility | | $2,747.00 | $5,208.93 | $7,920.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,806.92 / $5,453.17 / $6,139.72
| Professional | | $3,806.92 | $5,453.17 | $6,139.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.91 / $4,873.87 / $6,786.50
| Facility | | $2,600.91 | $4,873.87 | $6,786.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,525.22 / $4,637.52 / $4,998.20
| Facility | | $3,525.22 | $4,637.52 | $4,998.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,151.04 / $5,251.21 / $6,774.74
| Facility | | $3,151.04 | $5,251.21 | $6,774.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,852.96 / $12,852.96 / $12,852.96
| Facility | | $12,852.96 | $12,852.96 | $12,852.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,364.00 / $7,664.00 / $36,803.00
| Facility | | $2,364.00 | $7,664.00 | $36,803.00 |