- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,623.41 / $11,748.98
| Facility | | $1,862.09 | $5,623.41 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,623.41 / $10,232.93
| Professional | | $3,981.07 | $5,623.41 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $15,848.93 / $37,153.52
| Facility | | $5,128.61 | $15,848.93 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,165.95 / $12,022.64
| Professional | | $4,073.80 | $6,165.95 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $16,218.10 / $38,904.51
| Facility | | $11,748.98 | $16,218.10 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $13,182.57 / $18,620.87
| Professional | | $7,943.28 | $13,182.57 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $11,748.98
| Professional | | $3,981.07 | $5,888.44 | $11,748.98 |