- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $17,782.79
| Facility | | $3,715.35 | $5,011.87 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $4,365.16
| Professional | | $1,905.46 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $660.69 / $660.69
| Professional | | $602.56 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $26,302.68
| Facility | | $2,290.87 | $2,691.53 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,467.37 / $3,467.37
| Facility | | $1,479.11 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $4,897.79
| Professional | | $1,479.11 | $1,737.80 | $4,897.79 |