- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $18,197.01
| Facility | | $6,456.54 | $6,456.54 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,570.40
| Professional | | $1,412.54 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,897.79 / $14,791.08
| Facility | | $4,466.84 | $4,897.79 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $4,786.30
| Professional | | $1,659.59 | $1,659.59 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $8,128.31 / $11,220.18
| Facility | | $4,168.69 | $8,128.31 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $4,897.79
| Professional | | $2,570.40 | $2,570.40 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,570.40
| Professional | | $1,548.82 | $1,548.82 | $2,570.40 |