- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,413.10 / $13,489.63
| Facility | | $6,309.57 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,918.31
| Professional | | $4,897.79 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $4,897.79
| Facility | | $1,230.27 | $1,584.89 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $10,715.19 / $25,118.86
| Facility | | $1,778.28 | $10,715.19 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $2,754.23
| Facility | | $933.25 | $1,288.25 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,897.79 / $5,370.32
| Professional | | $1,096.48 | $4,897.79 | $5,370.32 |