- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,772.37 / $13,182.57
| Facility | | $2,398.83 | $9,772.37 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,623.41 / $10,232.93
| Professional | | $3,235.94 | $5,623.41 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,471.29 / $15,135.61
| Professional | | $4,570.88 | $10,471.29 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $9,332.54 / $14,454.40
| Professional | | $5,248.07 | $9,332.54 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $9,332.54 / $18,197.01
| Professional | | $5,011.87 | $9,332.54 | $18,197.01 |