- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,901.86 / $6,734.50 / $31,318.10
| Facility | | $2,901.86 | $6,734.50 | $31,318.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.86 / $4,106.39 / $4,653.92
| Professional | | $2,901.86 | $4,106.39 | $4,653.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,352.01 / $8,088.18 / $17,240.33
| Facility | | $5,352.01 | $8,088.18 | $17,240.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,832.64 / $7,172.51 / $9,975.81
| Professional | | $3,832.64 | $7,172.51 | $9,975.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,346.00 / $3,346.00 / $8,702.00
| Facility | | $3,346.00 | $3,346.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.08 / $3,285.12 / $5,612.08
| Professional | | $2,190.08 | $3,285.12 | $5,612.08 |