- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.64 / $5,475.80 / $13,141.90
| Facility | | $4,380.64 | $5,475.80 | $13,141.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,106.85 / $4,106.85 / $4,380.64
| Professional | | $4,106.85 | $4,106.85 | $4,380.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.27 / $3,559.27 / $4,805.01
| Facility | | $3,559.27 | $3,559.27 | $4,805.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,669.58 / $6,669.58 / $7,990.91
| Professional | | $6,669.58 | $6,669.58 | $7,990.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,106.85 / $5,475.80 / $9,199.34
| Facility | | $4,106.85 | $5,475.80 | $9,199.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $2,299.84 / $7,228.06
| Professional | | $2,299.84 | $2,299.84 | $7,228.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $2,299.84 / $5,475.80
| Professional | | $2,299.84 | $2,299.84 | $5,475.80 |