- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $9,120.11 / $21,877.62
| Facility | | $5,128.61 | $9,120.11 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,801.89 / $5,370.32
| Professional | | $3,019.95 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,128.31 / $17,378.01
| Facility | | $5,754.40 | $8,128.31 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $5,011.87
| Professional | | $3,019.95 | $3,019.95 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Professional | | $8,709.64 | $8,709.64 | $8,709.64 |