- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,309.57 / $15,135.61
| Facility | | $4,466.84 | $6,309.57 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,089.30 / $2,398.83
| Professional | | $1,905.46 | $2,089.30 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,025.60 / $12,022.64
| Facility | | $4,897.79 | $6,025.60 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,630.27
| Professional | | $1,905.46 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $2,238.72
| Professional | | $1,479.11 | $1,905.46 | $2,238.72 |