- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $20,417.38
| Facility | | $7,413.10 | $7,413.10 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $2,398.83
| Professional | | $1,584.89 | $2,290.87 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $16,982.44
| Facility | | $5,011.87 | $5,623.41 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $1,905.46
| Professional | | $1,174.90 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $9,120.11 / $12,882.50
| Facility | | $4,786.30 | $9,120.11 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $5,495.41
| Professional | | $2,884.03 | $2,884.03 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,884.03
| Professional | | $1,737.80 | $1,737.80 | $2,884.03 |