- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,005.00 / $10,563.53 / $20,928.72
| Facility | | $5,005.00 | $10,563.53 | $20,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,416.05 / $3,432.72 / $4,736.80
| Professional | | $3,416.05 | $3,432.72 | $4,736.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,533.80 / $2,223.57 / $3,902.23
| Facility | | $1,533.80 | $2,223.57 | $3,902.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,416.05 / $5,294.88 / $6,832.10
| Facility | | $3,416.05 | $5,294.88 | $6,832.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,541.77 / $7,380.38 / $10,920.01
| Professional | | $4,541.77 | $7,380.38 | $10,920.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,092.14 / $16,910.57 / $22,077.69
| Facility | | $14,092.14 | $16,910.57 | $22,077.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,082.80 / $5,082.80 / $5,082.80
| Professional | | $5,082.80 | $5,082.80 | $5,082.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,625.51 / $16,382.17 / $33,075.94
| Facility | | $12,625.51 | $16,382.17 | $33,075.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,541.77 / $7,165.31 / $9,462.03
| Professional | | $4,541.77 | $7,165.31 | $9,462.03 |