- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $10,715.19
| Facility | | $3,162.28 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $6,918.31
| Professional | | $2,818.38 | $3,311.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $11,481.54 / $23,988.33
| Facility | | $6,025.60 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,073.80 / $5,495.41
| Professional | | $3,162.28 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,265.80 / $5,623.41
| Professional | | $2,951.21 | $4,265.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $10,715.19
| Professional | | $3,467.37 | $3,467.37 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,884.03
| Professional | | $2,454.71 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,760.83 / $12,882.50
| Facility | | $2,630.27 | $6,760.83 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $6,918.31
| Professional | | $3,090.30 | $4,073.80 | $6,918.31 |