- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,011.87 / $7,762.47
| Facility | | $1,949.84 | $5,011.87 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,344.23
| Professional | | $1,479.11 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $14,454.40 / $20,892.96
| Facility | | $8,912.51 | $14,454.40 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $2,137.96
| Professional | | $1,288.25 | $1,949.84 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $15,135.61 / $23,988.33
| Facility | | $7,585.78 | $15,135.61 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $3,467.37
| Professional | | $1,621.81 | $2,041.74 | $3,467.37 |