- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,570.88 / $5,128.61
| Facility | | $2,511.89 | $4,570.88 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $4,570.88
| Professional | | $1,659.59 | $1,995.26 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $3,388.44
| Facility | | $3,235.94 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,698.24
| Facility | | $1,621.81 | $1,621.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,019.95
| Facility | | $2,238.72 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $5,623.41
| Professional | | $1,047.13 | $1,513.56 | $5,623.41 |