- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $8,511.38
| Facility | | $3,467.37 | $5,011.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $1,819.70
| Professional | | $1,174.90 | $1,479.11 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,623.41 / $16,218.10
| Professional | | $1,445.44 | $5,623.41 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $3,801.89
| Professional | | $1,380.38 | $1,949.84 | $3,801.89 |