- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,419.59 / $4,849.41 / $11,665.90
| Facility | | $3,419.59 | $4,849.41 | $11,665.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.73 / $1,674.75 / $1,933.58
| Professional | | $1,537.73 | $1,674.75 | $1,933.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,779.88 / $4,433.52 / $9,185.75
| Facility | | $2,779.88 | $4,433.52 | $9,185.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.50 / $1,522.50 / $1,735.65
| Professional | | $1,522.50 | $1,522.50 | $1,735.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,620.82 / $3,620.82 / $3,620.82
| Facility | | $3,620.82 | $3,620.82 | $3,620.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,162.39 / $16,162.39 / $16,162.39
| Professional | | $16,162.39 | $16,162.39 | $16,162.39 |