- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $20,417.38
| Facility | | $4,570.88 | $9,120.11 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,890.45
| Professional | | $2,818.38 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $9,120.11 / $25,703.96
| Facility | | $776.25 | $9,120.11 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $4,677.35 / $11,748.98
| Professional | | $933.25 | $4,677.35 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $12,882.50
| Facility | | $2,951.21 | $5,128.61 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,754.23 / $6,760.83
| Professional | | $467.74 | $2,754.23 | $6,760.83 |