- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $21,379.62
| Facility | | $7,762.47 | $7,762.47 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $2,630.27
| Professional | | $1,659.59 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,754.40 / $17,378.01
| Facility | | $5,248.07 | $5,754.40 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $2,884.03
| Professional | | $1,513.56 | $1,949.84 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $9,549.93 / $13,182.57
| Facility | | $4,897.79 | $9,549.93 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $5,754.40
| Professional | | $3,019.95 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $3,162.28
| Professional | | $1,819.70 | $1,819.70 | $3,162.28 |