- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,090.30 / $7,244.36
| Professional | | $2,630.27 | $3,090.30 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $19,498.45 / $21,379.62
| Facility | | $16,595.87 | $19,498.45 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,466.84 / $10,715.19
| Professional | | $2,884.03 | $4,466.84 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $5,370.32
| Professional | | $2,884.03 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,981.07 / $12,302.69
| Professional | | $2,691.53 | $3,981.07 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $6,918.31
| Professional | | $1,905.46 | $3,467.37 | $6,918.31 |