- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,471.29 / $12,589.25
| Facility | | $6,606.93 | $10,471.29 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,232.93 / $13,489.63
| Professional | | $6,606.93 | $10,232.93 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $32,359.37
| Facility | | $1,148.15 | $1,148.15 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,511.38 / $16,595.87
| Professional | | $5,370.32 | $8,511.38 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,715.19 / $10,715.19
| Facility | | $8,128.31 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $10,715.19 / $25,118.86
| Professional | | $1,288.25 | $10,715.19 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,778.28 / $7,762.47
| Facility | | $537.03 | $1,778.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,495.41 / $9,120.11
| Professional | | $3,801.89 | $5,495.41 | $9,120.11 |