- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $8,912.51 / $17,782.79
| Facility | | $4,677.35 | $8,912.51 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $4,786.30
| Professional | | $3,162.28 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $8,709.64 / $10,715.19
| Facility | | $4,365.16 | $8,709.64 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,786.30 / $6,456.54
| Facility | | $3,801.89 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $23,988.33
| Professional | | $1,995.26 | $2,884.03 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,786.30 / $5,754.40
| Facility | | $1,995.26 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $6,165.95
| Professional | | $1,995.26 | $2,884.03 | $6,165.95 |