- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $6,025.60 / $7,079.46
| Facility | | $1,513.56 | $6,025.60 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,888.44 / $7,413.10
| Professional | | $2,691.53 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,585.78 / $7,585.78
| Professional | | $3,981.07 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $15,488.17 / $26,915.35
| Facility | | $4,897.79 | $15,488.17 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36,307.81 / $36,307.81 / $36,307.81
| Facility | | $36,307.81 | $36,307.81 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,018.94 / $56,234.13 / $56,234.13
| Professional | | $38,018.94 | $56,234.13 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $7,585.78 / $7,585.78
| Facility | | $2,754.23 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,570.88 / $7,585.78
| Professional | | $3,162.28 | $4,570.88 | $7,585.78 |