- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,617.21 / $2,959.20 / $9,526.69
| Facility | | $2,617.21 | $2,959.20 | $9,526.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,617.21 / $2,721.91 / $2,966.19
| Professional | | $2,617.21 | $2,721.91 | $2,966.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.61 / $4,606.31 / $6,874.57
| Professional | | $1,814.61 | $4,606.31 | $6,874.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,336.81 / $7,518.71 / $12,459.78
| Facility | | $2,336.81 | $7,518.71 | $12,459.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.63 / $3,489.63 / $16,820.02
| Professional | | $3,489.63 | $3,489.63 | $16,820.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,071.96 / $16,575.74 / $16,575.74
| Facility | | $6,071.96 | $16,575.74 | $16,575.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,378.36 / $17,378.36 / $26,172.23
| Professional | | $17,378.36 | $17,378.36 | $26,172.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $2,093.78 / $3,489.63
| Professional | | $1,465.64 | $2,093.78 | $3,489.63 |