- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,220.18 / $26,302.68
| Facility | | $7,244.36 | $11,220.18 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,888.44 / $6,918.31
| Professional | | $4,786.30 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $21,379.62
| Facility | | $7,244.36 | $7,244.36 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $6,025.60
| Professional | | $2,884.03 | $2,884.03 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,760.83 / $13,182.57
| Facility | | $4,677.35 | $6,760.83 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,456.54 / $13,803.84
| Professional | | $3,235.94 | $6,456.54 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,365.16 / $7,244.36
| Professional | | $3,019.95 | $4,365.16 | $7,244.36 |