- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,943.28 / $14,454.40
| Facility | | $7,079.46 | $7,943.28 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $4,365.16
| Professional | | $1,819.70 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $11,220.18 / $21,877.62
| Facility | | $8,709.64 | $11,220.18 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $6,309.57
| Professional | | $5,495.41 | $6,025.60 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,467.37 / $7,943.28
| Facility | | $1,819.70 | $3,467.37 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,456.54 / $8,317.64
| Facility | | $3,715.35 | $6,456.54 | $8,317.64 |