- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,786.30 / $8,317.64
| Facility | | $2,089.30 | $4,786.30 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $15,848.93 / $15,848.93
| Professional | | $2,238.72 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $6,309.57 / $9,332.54
| Facility | | $1,949.84 | $6,309.57 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $6,165.95
| Professional | | $1,949.84 | $2,041.74 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,442.29 / $23,442.29 / $23,442.29
| Facility | | $23,442.29 | $23,442.29 | $23,442.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $13,803.84 / $22,387.21
| Facility | | $4,466.84 | $13,803.84 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,471.29 / $17,782.79
| Facility | | $4,570.88 | $10,471.29 | $17,782.79 |