- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $6,760.83 / $7,943.28
| Facility | | $1,659.59 | $6,760.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,309.57 / $7,244.36
| Professional | | $5,128.61 | $6,309.57 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $8,511.38 / $8,511.38
| Professional | | $4,365.16 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $17,378.01 / $30,199.52
| Facility | | $5,495.41 | $17,378.01 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Professional | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39,810.72 / $39,810.72 / $39,810.72
| Facility | | $39,810.72 | $39,810.72 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41,686.94 / $63,095.73 / $63,095.73
| Professional | | $41,686.94 | $63,095.73 | $63,095.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,715.35 / $8,511.38
| Facility | | $1,318.26 | $3,715.35 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $5,011.87
| Professional | | $1,548.82 | $2,187.76 | $5,011.87 |