- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,434.12 / $6,036.26 / $22,002.50
| Facility | | $4,434.12 | $6,036.26 | $22,002.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,509.88 / $4,977.93 / $5,438.07
| Professional | | $2,509.88 | $4,977.93 | $5,438.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,183.13 / $4,183.13 / $4,183.13
| Facility | | $4,183.13 | $4,183.13 | $4,183.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.03 / $2,719.03 / $2,719.03
| Facility | | $2,719.03 | $2,719.03 | $2,719.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.91 / $2,252.32 / $5,438.07
| Professional | | $1,756.91 | $2,252.32 | $5,438.07 |