- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $8,317.64 / $21,877.62
| Facility | | $4,073.80 | $8,317.64 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $5,495.41
| Professional | | $3,162.28 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,456.54 / $21,877.62
| Facility | | $4,786.30 | $6,456.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,801.89 / $7,943.28
| Professional | | $2,344.23 | $3,801.89 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $8,511.38 / $21,379.62
| Facility | | $3,090.30 | $8,511.38 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $13,182.57
| Professional | | $5,495.41 | $6,918.31 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,786.30 / $5,754.40
| Facility | | $2,884.03 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $5,754.40
| Professional | | $1,995.26 | $2,884.03 | $5,754.40 |