- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $16,595.87
| Facility | | $5,128.61 | $8,128.31 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,760.83
| Professional | | $5,128.61 | $5,128.61 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,709.64 / $17,782.79
| Facility | | $8,317.64 | $8,709.64 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $7,079.46 / $27,542.29
| Professional | | $3,548.13 | $7,079.46 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $5,754.40 / $28,840.32
| Facility | | $549.54 | $5,754.40 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $7,762.47 / $16,982.44
| Professional | | $1,202.26 | $7,762.47 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,120.11 / $30,199.52
| Facility | | $3,467.37 | $9,120.11 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $6,606.93
| Professional | | $2,754.23 | $3,548.13 | $6,606.93 |