- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,897.79 / $10,471.29
| Facility | | $4,466.84 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $6,025.60
| Professional | | $1,949.84 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $21,877.62 / $26,915.35
| Facility | | $8,912.51 | $21,877.62 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $5,011.87
| Professional | | $2,344.23 | $3,981.07 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,801.89 / $6,025.60
| Professional | | $2,754.23 | $3,801.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,786.30
| Professional | | $3,548.13 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $6,760.83
| Professional | | $2,290.87 | $3,311.31 | $6,760.83 |