- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,570.88 / $16,218.10
| Facility | | $3,311.31 | $4,570.88 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $4,073.80
| Professional | | $1,905.46 | $2,818.38 | $4,073.80 |
- 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
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $23,988.33
| Facility | | $2,041.74 | $2,041.74 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,162.28 / $3,162.28
| Facility | | $1,318.26 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $4,466.84
| Professional | | $1,318.26 | $1,584.89 | $4,466.84 |