- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.66 / $1,431.66 / $6,781.00
| Facility | | $1,431.66 | $1,431.66 | $6,781.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.55 / $1,431.66 / $1,467.35
| Professional | | $1,251.55 | $1,431.66 | $1,467.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,647.88 / $23,741.26 / $41,628.19
| Facility | | $15,647.88 | $23,741.26 | $41,628.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,302.69 / $2,947.26 / $25,103.03
| Facility | | $2,302.69 | $2,947.26 | $25,103.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.10 / $3,787.51 / $8,916.98
| Professional | | $2,056.10 | $3,787.51 | $8,916.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,577.00 / $10,743.00 / $12,774.00
| Facility | | $5,577.00 | $10,743.00 | $12,774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.78 / $3,787.51 / $6,428.53
| Professional | | $1,974.78 | $3,787.51 | $6,428.53 |