- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $9,549.93
| Facility | | $2,454.71 | $4,897.79 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $9,772.37 / $9,772.37
| Professional | | $7,762.47 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $11,481.54 / $15,848.93
| Facility | | $10,232.93 | $11,481.54 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $10,715.19
| Facility | | $2,454.71 | $4,897.79 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $9,772.37 / $13,803.84
| Professional | | $7,762.47 | $9,772.37 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $19,054.61
| Facility | | $2,511.89 | $7,244.36 | $19,054.61 |