- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $18,620.87
| Facility | | $3,890.45 | $5,248.07 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $4,677.35
| Professional | | $2,570.40 | $3,311.31 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,244.36 / $11,481.54
| Facility | | $3,981.07 | $7,244.36 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $28,183.83
| Facility | | $2,398.83 | $2,884.03 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,715.35 / $3,715.35
| Facility | | $1,548.82 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $5,128.61
| Professional | | $1,548.82 | $1,819.70 | $5,128.61 |