- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,025.60 / $25,118.86
| Facility | | $4,073.80 | $6,025.60 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,168.69 / $6,918.31
| Professional | | $3,801.89 | $4,168.69 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $14,791.08
| Facility | | $3,548.13 | $3,548.13 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $7,943.28
| Professional | | $6,606.93 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $9,549.93
| Facility | | $4,073.80 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $20,417.38
| Professional | | $2,290.87 | $2,290.87 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,495.41 / $6,606.93
| Facility | | $2,290.87 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,630.78
| Professional | | $2,290.87 | $2,290.87 | $3,630.78 |