- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,495.41 / $8,912.51
| Professional | | $3,311.31 | $5,495.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $18,620.87 / $22,387.21
| Professional | | $15,488.17 | $18,620.87 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,244.36 / $8,709.64
| Professional | | $5,623.41 | $7,244.36 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $12,882.50
| Professional | | $3,981.07 | $5,495.41 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,754.40 / $13,182.57
| Professional | | $4,168.69 | $5,754.40 | $13,182.57 |