- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $10,471.29
| Facility | | $3,162.28 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,168.69 / $6,606.93
| Professional | | $3,548.13 | $4,168.69 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $8,317.64
| Professional | | $3,890.45 | $5,248.07 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $4,168.69 / $6,918.31
| Facility | | $54.95 | $4,168.69 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $29,512.09
| Professional | | $3,890.45 | $4,786.30 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $6,918.31
| Professional | | $3,715.35 | $4,677.35 | $6,918.31 |