- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $3,981.07
| Professional | | $2,754.23 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $47,863.01 / $97,723.72
| Facility | | $22,908.68 | $47,863.01 | $97,723.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $7,079.46
| Professional | | $3,548.13 | $4,365.16 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,511.89 / $2,754.23
| Facility | | $2,344.23 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,818.38 / $3,890.45
| Facility | | $2,511.89 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,890.45
| Professional | | $2,398.83 | $3,235.94 | $3,890.45 |
- 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
- $1,949.84 / $2,754.23 / $4,466.84
| Professional | | $1,949.84 | $2,754.23 | $4,466.84 |