- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,332.54 / $18,197.01
| Facility | | $5,754.40 | $9,332.54 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,025.60 / $7,244.36
| Professional | | $5,754.40 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,585.78 / $15,488.17
| Facility | | $2,511.89 | $7,585.78 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,754.40 / $7,585.78
| Professional | | $2,089.30 | $5,754.40 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,165.95 / $8,511.38
| Facility | | $3,235.94 | $6,165.95 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $6,165.95 / $6,165.95
| Professional | | $2,754.23 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,248.07 / $9,772.37
| Facility | | $3,311.31 | $5,248.07 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,606.93 / $7,413.10
| Professional | | $6,025.60 | $6,606.93 | $7,413.10 |