- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $10,715.19
| Facility | | $3,162.28 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,623.41 / $13,182.57
| Professional | | $5,248.07 | $5,623.41 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $15,135.61 / $28,183.83
| Facility | | $7,762.47 | $15,135.61 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,943.28 / $10,964.78
| Professional | | $6,309.57 | $7,943.28 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $8,709.64 / $12,022.64
| Professional | | $6,165.95 | $8,709.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $21,379.62
| Professional | | $7,413.10 | $7,413.10 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,623.41
| Professional | | $5,248.07 | $5,248.07 | $5,623.41 |
- 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
- $6,606.93 / $8,709.64 / $14,791.08
| Professional | | $6,606.93 | $8,709.64 | $14,791.08 |