- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.41 / $1,023.41 / $5,618.00
| Facility | | $1,023.41 | $1,023.41 | $5,618.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.73 / $1,023.41 / $1,023.41
| Professional | | $894.73 | $1,023.41 | $1,023.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,655.83 / $40,442.72 / $70,912.73
| Facility | | $26,655.83 | $40,442.72 | $70,912.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.76 / $2,215.19 / $46,518.43
| Facility | | $1,721.76 | $2,215.19 | $46,518.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.88 / $2,370.44 / $4,771.53
| Professional | | $1,408.88 | $2,370.44 | $4,771.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,028.00 / $11,496.00 / $21,528.00
| Facility | | $5,028.00 | $11,496.00 | $21,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.29 / $2,269.64 / $4,467.53
| Professional | | $1,497.29 | $2,269.64 | $4,467.53 |