- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,709.64 / $22,908.68
| Facility | | $4,265.80 | $8,709.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $5,495.41
| Professional | | $3,311.31 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,456.54 / $22,908.68
| Facility | | $4,570.88 | $6,456.54 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $7,943.28
| Professional | | $1,995.26 | $2,454.71 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $8,511.38 / $21,379.62
| Facility | | $3,235.94 | $8,511.38 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,244.36 / $13,803.84
| Professional | | $5,754.40 | $7,244.36 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,011.87 / $6,025.60
| Facility | | $3,019.95 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $6,025.60
| Professional | | $2,089.30 | $3,019.95 | $6,025.60 |