- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,168.69 / $5,623.41
| Facility | | $3,890.45 | $4,168.69 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,073.80 / $5,011.87
| Professional | | $3,162.28 | $4,073.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,248.07 / $5,248.07
| Professional | | $2,691.53 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $10,715.19 / $18,620.87
| Facility | | $3,388.44 | $10,715.19 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,547.09 / $24,547.09 / $24,547.09
| Facility | | $24,547.09 | $24,547.09 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $38,904.51 / $38,904.51
| Professional | | $26,302.68 | $38,904.51 | $38,904.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,248.07 / $5,248.07
| Facility | | $1,862.09 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $5,248.07
| Professional | | $2,187.76 | $3,162.28 | $5,248.07 |