- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,438.12 / $3,447.25 / $3,447.25
| Professional | | $3,438.12 | $3,447.25 | $3,447.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,671.43 / $21,503.38 / $23,906.61
| Facility | | $16,671.43 | $21,503.38 | $23,906.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $7,819.00 / $19,195.00
| Facility | | $5,074.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.44 / $1,631.26 / $28,397.73
| Professional | | $825.44 | $1,631.26 | $28,397.73 |