- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,754.40 / $10,471.29
| Facility | | $4,570.88 | $5,754.40 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,168.69 / $7,585.78
| Professional | | $3,311.31 | $4,168.69 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $17,378.01 / $19,952.62
| Facility | | $8,709.64 | $17,378.01 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,585.78 / $8,709.64
| Professional | | $3,388.44 | $7,585.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,888.44 / $9,332.54
| Professional | | $3,890.45 | $5,888.44 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $6,456.54
| Professional | | $5,623.41 | $5,623.41 | $6,456.54 |
- 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
- $3,630.78 / $5,623.41 / $10,964.78
| Professional | | $3,630.78 | $5,623.41 | $10,964.78 |