- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,495.41 / $10,715.19
| Facility | | $2,951.21 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $6,606.93
| Professional | | $2,754.23 | $3,388.44 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $17,378.01
| Facility | | $4,570.88 | $9,549.93 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,570.88 / $7,244.36
| Professional | | $3,548.13 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,168.69 / $6,606.93
| Professional | | $3,019.95 | $4,168.69 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,168.69 / $11,481.54
| Professional | | $2,951.21 | $4,168.69 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $4,466.84
| Professional | | $2,951.21 | $2,951.21 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $18,620.87
| Facility | | $8,511.38 | $12,022.64 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,168.69 / $7,762.47
| Professional | | $2,951.21 | $4,168.69 | $7,762.47 |