- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,677.35 / $8,317.64
| Facility | | $2,137.96 | $4,677.35 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $22,908.68 / $22,908.68
| Professional | | $2,238.72 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $6,309.57 / $9,332.54
| Facility | | $1,949.84 | $6,309.57 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $6,165.95
| Professional | | $1,949.84 | $2,041.74 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Facility | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $9,332.54 / $33,113.11
| Facility | | $5,888.44 | $9,332.54 | $33,113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,413.10 / $10,964.78
| Facility | | $5,370.32 | $7,413.10 | $10,964.78 |