- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,481.54 / $26,915.35
| Facility | | $5,370.32 | $11,481.54 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $4,073.80
| Professional | | $3,019.95 | $3,019.95 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $9,549.93 / $27,542.29
| Facility | | $870.96 | $9,549.93 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,019.95 / $12,302.69
| Professional | | $1,023.29 | $3,019.95 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $8,912.51 / $17,378.01
| Facility | | $3,388.44 | $8,912.51 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $3,019.95 / $7,943.28
| Professional | | $524.81 | $3,019.95 | $7,943.28 |