- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,964.78 / $13,182.57
| Facility | | $6,760.83 | $10,964.78 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,715.19 / $14,125.38
| Professional | | $6,760.83 | $10,715.19 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $33,884.42
| Facility | | $1,202.26 | $1,202.26 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $13,489.63 / $18,620.87
| Professional | | $6,760.83 | $13,489.63 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,220.18 / $11,220.18
| Facility | | $8,511.38 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,220.18 / $26,302.68
| Professional | | $5,011.87 | $11,220.18 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,862.09 / $8,128.31
| Facility | | $549.54 | $1,862.09 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,754.40 / $9,772.37
| Professional | | $3,981.07 | $5,754.40 | $9,772.37 |