- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,897.79 / $4,897.79
| Facility | | $2,344.23 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,890.45 / $6,025.60
| Professional | | $3,311.31 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,495.41 / $8,317.64
| Professional | | $3,548.13 | $5,495.41 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $3,715.35
| Facility | | $3,162.28 | $3,467.37 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $6,918.31
| Facility | | $3,467.37 | $5,370.32 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $10,232.93
| Professional | | $3,235.94 | $4,570.88 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,570.88 / $7,413.10
| Professional | | $3,162.28 | $4,570.88 | $7,413.10 |