- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,980.51 / $5,816.00 / $23,998.49
| Facility | | $3,980.51 | $5,816.00 | $23,998.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.43 / $1,387.46 / $1,548.84
| Professional | | $1,328.43 | $1,387.46 | $1,548.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.83 / $1,595.59 / $2,888.21
| Professional | | $1,352.83 | $1,595.59 | $2,888.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,717.13 / $14,717.13 / $14,717.13
| Facility | | $14,717.13 | $14,717.13 | $14,717.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.21 / $1,526.47 / $3,553.29
| Professional | | $1,314.21 | $1,526.47 | $3,553.29 |