- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $25,118.86
| Facility | | $9,120.11 | $9,120.11 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $3,162.28
| Professional | | $1,949.84 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,918.31 / $20,892.96
| Facility | | $6,165.95 | $6,918.31 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $2,344.23
| Professional | | $1,445.44 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $11,220.18 / $15,848.93
| Facility | | $5,888.44 | $11,220.18 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $6,918.31
| Professional | | $3,630.78 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $3,801.89
| Professional | | $2,137.96 | $2,137.96 | $3,801.89 |