- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,176.17 / $8,682.35 / $20,886.56
| Facility | | $5,176.17 | $8,682.35 | $20,886.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,032.12 / $3,812.66 / $5,289.72
| Professional | | $3,032.12 | $3,812.66 | $5,289.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,745.20 / $7,937.75 / $16,446.11
| Facility | | $4,745.20 | $7,937.75 | $16,446.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.10 / $3,002.10 / $4,745.20
| Professional | | $3,002.10 | $3,002.10 | $4,745.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,647.62 / $3,647.62 / $3,647.62
| Facility | | $3,647.62 | $3,647.62 | $3,647.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,804.60 / $8,804.60 / $8,804.60
| Professional | | $8,804.60 | $8,804.60 | $8,804.60 |