- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,584.14 / $7,154.67 / $17,211.52
| Facility | | $4,584.14 | $7,154.67 | $17,211.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.71 / $2,470.88 / $2,852.74
| Professional | | $2,268.71 | $2,470.88 | $2,852.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,972.57 / $6,541.08 / $13,552.38
| Facility | | $3,972.57 | $6,541.08 | $13,552.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,246.25 / $2,246.25 / $2,994.18
| Professional | | $2,246.25 | $2,246.25 | $2,994.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,943.50 / $2,943.50 / $3,712.36
| Facility | | $2,943.50 | $2,943.50 | $3,712.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,105.00 / $7,105.00 / $7,105.00
| Professional | | $7,105.00 | $7,105.00 | $7,105.00 |