- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,227.96 / $14,227.96 / $22,359.16
| Facility | | $14,227.96 | $14,227.96 | $22,359.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.32 / $1,550.08 / $1,927.52
| Professional | | $1,329.32 | $1,550.08 | $1,927.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,571.92 / $15,944.12 / $17,147.93
| Facility | | $7,571.92 | $15,944.12 | $17,147.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,647.91 / $2,986.89 / $4,536.01
| Professional | | $2,647.91 | $2,986.89 | $4,536.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.97 / $2,263.83 / $3,021.88
| Professional | | $1,527.97 | $2,263.83 | $3,021.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.97 / $2,241.73 / $3,021.88
| Professional | | $1,527.97 | $2,241.73 | $3,021.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.08 / $1,996.86 / $5,517.60
| Professional | | $1,867.08 | $1,996.86 | $5,517.60 |