- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,440.91 / $7,023.55 / $12,121.10
| Facility | | $4,440.91 | $7,023.55 | $12,121.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,970.70 / $4,440.91 / $5,067.85
| Professional | | $3,970.70 | $4,440.91 | $5,067.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.00 / $4,662.95 / $9,253.59
| Professional | | $1,912.00 | $4,662.95 | $9,253.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,196.10 / $10,089.49 / $12,453.10
| Facility | | $7,196.10 | $10,089.49 | $12,453.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,063.82 / $6,063.82 / $6,063.82
| Professional | | $6,063.82 | $6,063.82 | $6,063.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,440.91 / $6,269.52 / $24,816.85
| Facility | | $4,440.91 | $6,269.52 | $24,816.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $26,018.51
| Professional | | $2,194.33 | $3,134.76 | $26,018.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,702.14 / $4,702.14 / $6,269.52
| Facility | | $4,702.14 | $4,702.14 | $6,269.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $5,909.02
| Professional | | $2,194.33 | $3,134.76 | $5,909.02 |