- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,943.28 / $9,549.93
| Facility | | $4,897.79 | $7,943.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,762.47 / $10,232.93
| Professional | | $4,897.79 | $7,762.47 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $24,547.09
| Facility | | $870.96 | $870.96 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,456.54 / $12,589.25
| Professional | | $4,786.30 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $8,128.31 / $8,128.31
| Facility | | $6,309.57 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $8,128.31 / $19,054.61
| Professional | | $977.24 | $8,128.31 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,348.96 / $5,888.44
| Facility | | $398.11 | $1,348.96 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,168.69 / $7,244.36
| Professional | | $2,884.03 | $4,168.69 | $7,244.36 |