- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,606.93 / $17,782.79
| Facility | | $3,162.28 | $6,606.93 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $5,754.40
| Professional | | $2,570.40 | $3,162.28 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $17,782.79
| Facility | | $3,630.78 | $5,011.87 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $6,309.57
| Professional | | $1,548.82 | $1,778.28 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,309.57 / $16,595.87
| Facility | | $2,511.89 | $6,309.57 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,677.35 / $9,332.54
| Professional | | $1,819.70 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $4,677.35
| Facility | | $2,344.23 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $4,677.35
| Professional | | $1,621.81 | $2,344.23 | $4,677.35 |