- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,391.46 / $6,739.33 / $16,174.40
| Facility | | $5,391.46 | $6,739.33 | $16,174.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,054.50 / $5,054.50 / $5,391.46
| Professional | | $5,054.50 | $5,054.50 | $5,391.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.56 / $4,380.56 / $5,913.76
| Facility | | $4,380.56 | $4,380.56 | $5,913.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,208.81 / $8,208.81 / $9,835.09
| Professional | | $8,208.81 | $8,208.81 | $9,835.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,054.50 / $6,739.33 / $11,322.07
| Facility | | $5,054.50 | $6,739.33 | $11,322.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $2,830.52 / $8,895.92
| Professional | | $2,830.52 | $2,830.52 | $8,895.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $2,830.52 / $4,313.17
| Professional | | $2,830.52 | $2,830.52 | $4,313.17 |