- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,481.54 / $11,481.54
| Facility | | $7,244.36 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,737.80 / $2,041.74
| Professional | | $1,659.59 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $3,090.30
| Facility | | $2,630.27 | $2,884.03 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,630.78
| Professional | | $1,047.13 | $1,513.56 | $3,630.78 |