- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,106.39 / $4,642.97 / $14,947.30
| Facility | | $4,106.39 | $4,642.97 | $14,947.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,106.39 / $4,270.66 / $4,653.92
| Professional | | $4,106.39 | $4,270.66 | $4,653.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.10 / $7,227.26 / $10,786.14
| Professional | | $2,847.10 | $7,227.26 | $10,786.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,612.26 / $11,796.44 / $19,549.58
| Facility | | $3,612.26 | $11,796.44 | $19,549.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,475.20 / $26,390.46
| Professional | | $5,475.20 | $5,475.20 | $26,390.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,526.85 / $26,007.20 / $26,007.20
| Facility | | $9,526.85 | $26,007.20 | $26,007.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,266.50 / $27,266.50 / $41,064.00
| Professional | | $27,266.50 | $27,266.50 | $41,064.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $5,475.20
| Professional | | $2,299.58 | $3,285.12 | $5,475.20 |