- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,603.13 / $6,531.17 / $15,711.61
| Facility | | $4,603.13 | $6,531.17 | $15,711.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,556.61 / $5,624.93 / $8,092.96
| Professional | | $3,556.61 | $5,624.93 | $8,092.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.66 / $5,971.06 / $12,371.35
| Facility | | $4,184.66 | $5,971.06 | $12,371.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,097.08 / $4,910.39 / $7,421.72
| Professional | | $3,097.08 | $4,910.39 | $7,421.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,173.93 / $5,173.93 / $5,173.93
| Facility | | $5,173.93 | $5,173.93 | $5,173.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.00 / $10,732.74 / $10,732.74
| Professional | | $2,473.00 | $10,732.74 | $10,732.74 |