- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $6,025.60 / $10,715.19
| Facility | | $1,584.89 | $6,025.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $24,547.09 / $30,902.95
| Facility | | $15,488.17 | $24,547.09 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,754.40 / $10,715.19
| Facility | | $1,288.25 | $5,754.40 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $4,786.30
| Professional | | $3,801.89 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,495.41 / $29,512.09
| Facility | | $2,454.71 | $5,495.41 | $29,512.09 |