- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $22,908.68 / $22,908.68
| Facility | | $10,471.29 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,495.41 / $8,511.38
| Professional | | $4,677.35 | $5,495.41 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $14,454.40
| Professional | | $10,471.29 | $10,471.29 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $12,882.50
| Facility | | $4,466.84 | $8,128.31 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,413.10 / $7,413.10
| Professional | | $7,079.46 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $4,073.80
| Professional | | $2,818.38 | $2,818.38 | $4,073.80 |