- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,931.35 / $5,578.01 / $13,418.66
| Facility | | $3,931.35 | $5,578.01 | $13,418.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,037.55 / $4,804.03 / $6,911.87
| Professional | | $3,037.55 | $4,804.03 | $6,911.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,573.95 / $5,099.64 / $10,565.88
| Facility | | $3,573.95 | $5,099.64 | $10,565.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.09 / $4,193.78 / $6,338.59
| Professional | | $2,645.09 | $4,193.78 | $6,338.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,417.70 / $4,417.70 / $4,417.70
| Facility | | $4,417.70 | $4,417.70 | $4,417.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.00 / $9,115.20 / $9,115.20
| Professional | | $2,336.00 | $9,115.20 | $9,115.20 |