- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.10 / $3,020.94 / $18,367.30
| Facility | | $2,711.10 | $3,020.94 | $18,367.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,020.94 / $3,020.94 / $3,098.40
| Professional | | $3,020.94 | $3,020.94 | $3,098.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,843.82 / $23,843.82 / $25,481.34
| Facility | | $23,843.82 | $23,843.82 | $25,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $3,873.00 / $5,296.33
| Professional | | $3,873.00 | $3,873.00 | $5,296.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,038.79 / $9,541.14 / $22,083.07
| Facility | | $7,038.79 | $9,541.14 | $22,083.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.71 / $2,265.71 / $2,265.71
| Professional | | $2,265.71 | $2,265.71 | $2,265.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,020.94 / $3,873.00 / $4,686.33
| Facility | | $3,020.94 | $3,873.00 | $4,686.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,130.15 / $3,526.79
| Professional | | $1,626.66 | $2,130.15 | $3,526.79 |