- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,309.57 / $9,549.93
| Facility | | $4,570.88 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,760.83
| Professional | | $3,467.37 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $17,378.01 / $31,622.78
| Facility | | $8,912.51 | $17,378.01 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,479.11 / $2,089.30
| Professional | | $660.69 | $1,479.11 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $12,589.25 / $21,877.62
| Facility | | $8,912.51 | $12,589.25 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,041.74 / $22,387.21
| Professional | | $1,023.29 | $2,041.74 | $22,387.21 |