- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.68 / $2,132.69 / $15,404.91
| Facility | | $1,879.68 | $2,132.69 | $15,404.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.34 / $1,510.65 / $1,802.87
| Professional | | $1,243.34 | $1,510.65 | $1,802.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,499.20 / $14,232.40 / $28,684.04
| Facility | | $12,499.20 | $14,232.40 | $28,684.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.03 / $2,924.58 / $4,540.37
| Professional | | $2,481.03 | $2,924.58 | $4,540.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.15 / $2,266.59 / $3,025.25
| Professional | | $1,429.15 | $2,266.59 | $3,025.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.15 / $2,095.67 / $3,025.25
| Professional | | $1,429.15 | $2,095.67 | $3,025.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.45 / $1,900.11 / $5,523.75
| Professional | | $1,792.45 | $1,900.11 | $5,523.75 |