- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,928.19 / $3,262.85 / $19,838.09
| Facility | | $2,928.19 | $3,262.85 | $19,838.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,262.85 / $3,262.85 / $3,346.51
| Professional | | $3,262.85 | $3,262.85 | $3,346.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,183.13 / $4,183.13 / $5,720.43
| Professional | | $4,183.13 | $4,183.13 | $5,720.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,602.41 / $10,305.12 / $23,851.33
| Facility | | $7,602.41 | $10,305.12 | $23,851.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,928.20 / $4,183.13 / $5,187.09
| Facility | | $2,928.20 | $4,183.13 | $5,187.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.91 / $2,385.96 / $3,809.20
| Professional | | $1,756.91 | $2,385.96 | $3,809.20 |