- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,244.36 / $16,218.10
| Facility | | $6,165.95 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,760.83
| Professional | | $4,786.30 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $7,079.46
| Facility | | $4,466.84 | $5,495.41 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,589.25 / $25,703.96
| Facility | | $4,677.35 | $12,589.25 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,754.40 / $8,128.31
| Facility | | $3,981.07 | $5,754.40 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,495.41
| Professional | | $4,786.30 | $4,786.30 | $5,495.41 |