- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,548.13 / $7,585.78
| Facility | | $1,513.56 | $3,548.13 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,290.87
| Professional | | $1,096.48 | $1,548.82 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $12,302.69 / $19,498.45
| Facility | | $6,456.54 | $12,302.69 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $4,677.35
| Professional | | $1,862.09 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,882.50 / $15,488.17 / $15,488.17
| Professional | | $12,882.50 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $18,620.87 / $42,657.95
| Facility | | $10,715.19 | $18,620.87 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $3,548.13
| Professional | | $1,659.59 | $2,137.96 | $3,548.13 |