- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,309.57 / $9,549.93
| Facility | | $3,890.45 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $12,022.64
| Facility | | $2,238.72 | $5,888.44 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $67.61 / $67.61
| Professional | | $51.29 | $67.61 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,762.47 / $17,378.01
| Facility | | $1,995.26 | $7,762.47 | $17,378.01 |