- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,468.21 / $1,468.21 / $11,009.00
| Facility | | $1,468.21 | $1,468.21 | $11,009.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.36 / $1,468.21 / $1,758.69
| Professional | | $1,397.36 | $1,468.21 | $1,758.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,540.35 / $26,444.67 / $45,003.43
| Facility | | $15,540.35 | $26,444.67 | $45,003.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.97 / $2,400.54 / $3,954.00
| Facility | | $1,618.97 | $2,400.54 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,331.04 / $4,007.12 / $8,066.16
| Professional | | $2,331.04 | $4,007.12 | $8,066.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.97 / $3,836.54 / $7,551.78
| Professional | | $2,036.97 | $3,836.54 | $7,551.78 |