- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $6,760.83 / $8,709.64
| Facility | | $1,380.38 | $6,760.83 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,677.35 / $5,370.32
| Professional | | $1,288.25 | $4,677.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $3,311.31
| Professional | | $1,548.82 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $16,595.87
| Professional | | $13,489.63 | $13,489.63 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,370.32 / $9,120.11
| Facility | | $1,412.54 | $5,370.32 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $21,379.62 / $28,840.32
| Facility | | $9,120.11 | $21,379.62 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,818.38
| Professional | | $870.96 | $1,288.25 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66,069.34 / $66,069.34 / $66,069.34
| Facility | | $66,069.34 | $66,069.34 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,018.94 / $45,708.82 / $45,708.82
| Professional | | $38,018.94 | $45,708.82 | $45,708.82 |