- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,897.79 / $6,918.31
| Facility | | $4,786.30 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $676.08
| Professional | | $389.05 | $575.44 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $16,982.44 / $17,782.79
| Professional | | $10,964.78 | $16,982.44 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,897.79 / $6,918.31
| Facility | | $4,786.30 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $575.44 / $645.65
| Professional | | $416.87 | $575.44 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $12,589.25 / $37,153.52
| Facility | | $6,918.31 | $12,589.25 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $831.76 / $1,122.02
| Professional | | $630.96 | $831.76 | $1,122.02 |