- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $7,762.47 / $18,620.87
| Facility | | $1,698.24 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $2,290.87
| Professional | | $1,905.46 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $20,417.38 / $37,153.52
| Facility | | $13,803.84 | $20,417.38 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,011.87
| Professional | | $3,890.45 | $3,890.45 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $5,248.07
| Professional | | $1,819.70 | $2,691.53 | $5,248.07 |