- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,833.06 / $4,271.12 / $25,968.40
| Facility | | $3,833.06 | $4,271.12 | $25,968.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,271.12 / $4,271.12 / $4,763.95
| Professional | | $4,271.12 | $4,271.12 | $4,763.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.80 / $5,475.80 / $7,488.16
| Professional | | $5,475.80 | $5,475.80 | $7,488.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,648.78 / $11,104.92 / $31,221.92
| Facility | | $3,648.78 | $11,104.92 | $31,221.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,216.37 / $5,475.80 / $5,859.11
| Facility | | $4,216.37 | $5,475.80 | $5,859.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $2,737.90 / $4,986.32
| Professional | | $2,299.84 | $2,737.90 | $4,986.32 |