- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,028.25 / $7,134.36 / $17,162.66
| Facility | | $5,028.25 | $7,134.36 | $17,162.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.27 / $2,463.86 / $2,844.64
| Professional | | $2,262.27 | $2,463.86 | $2,844.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,089.71 / $6,522.52 / $13,513.91
| Facility | | $4,089.71 | $6,522.52 | $13,513.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.88 / $2,239.88 / $2,799.84
| Professional | | $2,239.88 | $2,239.88 | $2,799.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.68 / $1,388.68 / $1,388.68
| Facility | | $1,388.68 | $1,388.68 | $1,388.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,504.72 / $5,504.72 / $5,504.72
| Professional | | $5,504.72 | $5,504.72 | $5,504.72 |