- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,495.41 / $10,471.29
| Facility | | $4,570.88 | $5,495.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $8,317.64
| Professional | | $2,511.89 | $3,388.44 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,848.93 / $16,595.87
| Facility | | $8,317.64 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,623.41 / $7,244.36
| Professional | | $2,884.03 | $5,623.41 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,786.30 / $7,762.47
| Professional | | $3,235.94 | $4,786.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,128.61
| Professional | | $4,786.30 | $4,786.30 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,981.07 / $7,585.78
| Professional | | $2,630.27 | $3,981.07 | $7,585.78 |