- 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
- $2,344.23 / $2,951.21 / $6,760.83
| Professional | | $2,344.23 | $2,951.21 | $6,760.83 |
- 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
- $2,691.53 / $4,786.30 / $6,025.60
| Professional | | $2,691.53 | $4,786.30 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $7,585.78
| Professional | | $3,311.31 | $3,981.07 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,754.40
| Professional | | $4,073.80 | $4,073.80 | $5,754.40 |
- 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
- $2,570.40 / $3,801.89 / $8,128.31
| Professional | | $2,570.40 | $3,801.89 | $8,128.31 |