- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $9,120.11 / $10,232.93
| Facility | | $5,011.87 | $9,120.11 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,073.80 / $9,120.11
| Professional | | $3,715.35 | $4,073.80 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,388.44
| Facility | | $3,235.94 | $3,235.94 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $6,025.60
| Facility | | $4,466.84 | $4,466.84 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $11,220.18
| Professional | | $2,089.30 | $3,019.95 | $11,220.18 |