- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,168.69 / $8,511.38
| Facility | | $4,073.80 | $4,168.69 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,168.69 / $6,760.83
| Professional | | $2,754.23 | $4,168.69 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $8,912.51 / $10,471.29
| Professional | | $7,079.46 | $8,912.51 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,918.31 / $11,748.98
| Professional | | $5,623.41 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $12,302.69
| Facility | | $4,073.80 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $7,413.10 / $9,549.93
| Professional | | $1,584.89 | $7,413.10 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $7,585.78 / $10,232.93
| Professional | | $1,584.89 | $7,585.78 | $10,232.93 |