- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $11,220.18 / $18,197.01
| Facility | | $7,943.28 | $11,220.18 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $1,819.70
| Professional | | $1,621.81 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,413.10 / $12,589.25
| Facility | | $4,073.80 | $7,413.10 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $3,801.89
| Facility | | $1,621.81 | $1,995.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $11,220.18 / $17,378.01
| Facility | | $2,754.23 | $11,220.18 | $17,378.01 |