- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,384.16 / $4,801.63 / $11,550.97
| Facility | | $3,384.16 | $4,801.63 | $11,550.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,614.77 / $4,135.37 / $5,949.83
| Professional | | $2,614.77 | $4,135.37 | $5,949.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.51 / $4,389.84 / $9,095.25
| Facility | | $3,076.51 | $4,389.84 | $9,095.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.92 / $3,610.06 / $5,456.35
| Professional | | $2,276.92 | $3,610.06 | $5,456.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,802.71 / $3,802.71 / $3,802.71
| Facility | | $3,802.71 | $3,802.71 | $3,802.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.00 / $7,846.44 / $7,846.44
| Professional | | $2,012.00 | $7,846.44 | $7,846.44 |