- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,257.13 / $6,040.26 / $14,530.66
| Facility | | $4,257.13 | $6,040.26 | $14,530.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.34 / $2,086.01 / $2,408.40
| Professional | | $1,915.34 | $2,086.01 | $2,408.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,870.12 / $5,522.24 / $11,441.46
| Facility | | $3,870.12 | $5,522.24 | $11,441.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.38 / $1,896.38 / $1,896.38
| Professional | | $1,896.38 | $1,896.38 | $1,896.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,023.35 / $3,023.35 / $3,023.35
| Facility | | $3,023.35 | $3,023.35 | $3,023.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,166.74 / $5,166.74 / $5,166.74
| Professional | | $5,166.74 | $5,166.74 | $5,166.74 |