- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,471.29 / $15,135.61
| Facility | | $4,570.88 | $10,471.29 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $2,398.83
| Professional | | $1,230.27 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $22,908.68 / $31,622.78
| Facility | | $8,912.51 | $22,908.68 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $3,235.94
| Professional | | $1,258.93 | $2,630.27 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $31,622.78 / $47,863.01
| Facility | | $13,803.84 | $31,622.78 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,951.21 / $5,888.44
| Professional | | $1,778.28 | $2,951.21 | $5,888.44 |