- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,585.78 / $22,908.68
| Facility | | $5,623.41 | $7,585.78 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,623.41 / $7,585.78
| Professional | | $2,691.53 | $5,623.41 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $20,417.38
| Facility | | $4,897.79 | $4,897.79 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $10,964.78
| Professional | | $9,332.54 | $9,332.54 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,585.78 / $13,182.57
| Facility | | $5,623.41 | $7,585.78 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $28,183.83
| Professional | | $3,162.28 | $3,162.28 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,585.78 / $9,120.11
| Facility | | $3,162.28 | $7,585.78 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $5,011.87
| Professional | | $3,162.28 | $3,162.28 | $5,011.87 |