- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,106.85 / $4,643.47 / $14,948.90
| Facility | | $4,106.85 | $4,643.47 | $14,948.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,106.85 / $4,271.12 / $4,654.43
| Professional | | $4,106.85 | $4,271.12 | $4,654.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.42 / $7,228.06 / $10,787.33
| Professional | | $2,847.42 | $7,228.06 | $10,787.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,666.85 / $11,797.90 / $19,551.91
| Facility | | $3,666.85 | $11,797.90 | $19,551.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.80 / $5,475.80 / $26,393.36
| Professional | | $5,475.80 | $5,475.80 | $26,393.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,527.89 / $26,010.05 / $26,010.05
| Facility | | $9,527.89 | $26,010.05 | $26,010.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,269.48 / $27,269.48 / $41,068.50
| Professional | | $27,269.48 | $27,269.48 | $41,068.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $5,475.80
| Professional | | $2,299.84 | $3,285.48 | $5,475.80 |