- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,675.25 / $8,357.16 / $16,538.59
| Facility | | $3,675.25 | $8,357.16 | $16,538.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,697.44 / $3,697.44
| Professional | | $3,660.83 | $3,697.44 | $3,697.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $7,321.66 / $9,701.20
| Facility | | $3,660.83 | $7,321.66 | $9,701.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,111.70 / $3,660.83 / $5,198.37
| Professional | | $3,111.70 | $3,660.83 | $5,198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $5,491.25
| Facility | | $3,660.83 | $3,660.83 | $5,491.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,576.04
| Professional | | $3,660.83 | $3,660.83 | $4,576.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $7,994.46
| Facility | | $3,660.83 | $3,660.83 | $7,994.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,194.98 / $3,660.83 / $9,575.91
| Professional | | $3,194.98 | $3,660.83 | $9,575.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,577.87
| Professional | | $3,660.83 | $3,660.83 | $4,577.87 |