- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $8,511.38
| Facility | | $3,981.07 | $4,265.80 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,265.80 / $6,309.57
| Professional | | $3,801.89 | $4,265.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $9,772.37 / $11,481.54
| Professional | | $7,943.28 | $9,772.37 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,762.47 / $13,489.63
| Professional | | $5,754.40 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,165.95 / $12,882.50
| Facility | | $4,265.80 | $6,165.95 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,762.47 / $9,332.54
| Professional | | $4,365.16 | $7,762.47 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,762.47 / $10,471.29
| Professional | | $4,365.16 | $7,762.47 | $10,471.29 |