- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,248.07 / $10,471.29
| Facility | | $4,570.88 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $7,585.78
| Professional | | $2,454.71 | $3,019.95 | $7,585.78 |
- 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
- $2,754.23 / $5,495.41 / $7,079.46
| Professional | | $2,754.23 | $5,495.41 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,570.88 / $7,244.36
| Professional | | $3,548.13 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- 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
- $2,630.27 / $3,715.35 / $7,943.28
| Professional | | $2,630.27 | $3,715.35 | $7,943.28 |