- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,623.41 / $19,952.62
| Facility | | $4,073.80 | $5,623.41 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $4,897.79
| Professional | | $2,344.23 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,918.31 / $9,549.93
| Facility | | $4,073.80 | $6,918.31 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $4,786.30
| Professional | | $602.56 | $602.56 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,413.10 / $29,512.09
| Facility | | $2,511.89 | $7,413.10 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,890.45 / $3,890.45
| Facility | | $1,621.81 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $5,370.32
| Professional | | $1,621.81 | $1,949.84 | $5,370.32 |