- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,128.31 / $28,183.83
| Facility | | $4,265.80 | $8,128.31 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,128.61 / $8,511.38
| Professional | | $4,265.80 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,128.31 / $20,892.96
| Facility | | $6,025.60 | $8,128.31 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,943.28 / $13,182.57
| Professional | | $5,248.07 | $7,943.28 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $38,904.51
| Facility | | $7,943.28 | $7,943.28 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $14,791.08
| Professional | | $6,760.83 | $6,760.83 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,918.31 / $12,302.69
| Facility | | $5,011.87 | $6,918.31 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $7,762.47
| Professional | | $3,715.35 | $5,011.87 | $7,762.47 |