- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,585.78 / $17,782.79
| Facility | | $5,248.07 | $7,585.78 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $2,884.03
| Professional | | $2,290.87 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,244.36 / $14,125.38
| Facility | | $5,754.40 | $7,244.36 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,162.28
| Professional | | $2,238.72 | $2,238.72 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,715.35
| Facility | | $2,951.21 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Professional | | $7,079.46 | $7,079.46 | $7,079.46 |