- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,897.79 / $5,754.40
| Facility | | $2,344.23 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $6,918.31
| Professional | | $3,467.37 | $4,073.80 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $30,199.52 / $41,686.94
| Facility | | $12,589.25 | $30,199.52 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $6,606.93
| Professional | | $3,388.44 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,801.89 / $4,265.80
| Facility | | $3,630.78 | $3,801.89 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,025.60 / $8,128.31
| Facility | | $3,801.89 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $8,128.31
| Professional | | $3,630.78 | $4,897.79 | $8,128.31 |
- 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
- $3,467.37 / $4,365.16 / $7,244.36
| Professional | | $3,467.37 | $4,365.16 | $7,244.36 |