- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,760.83 / $9,120.11
| Facility | | $3,715.35 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $3,715.35
| Professional | | $2,454.71 | $2,818.38 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $5,011.87
| Facility | | $4,786.30 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,511.89
| Facility | | $2,398.83 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $4,365.16
| Facility | | $3,311.31 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $8,128.31
| Professional | | $1,548.82 | $2,187.76 | $8,128.31 |