- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,897.79 / $10,471.29
| Facility | | $4,570.88 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $5,888.44
| Professional | | $2,137.96 | $2,818.38 | $5,888.44 |
- 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 / $4,677.35 / $5,888.44
| Professional | | $2,344.23 | $4,677.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,073.80 / $6,456.54
| Professional | | $3,019.95 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,370.32
| Professional | | $4,073.80 | $4,073.80 | $5,370.32 |
- 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
- $2,238.72 / $3,311.31 / $7,244.36
| Professional | | $2,238.72 | $3,311.31 | $7,244.36 |