- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,943.28 / $28,183.83
| Facility | | $5,754.40 | $7,943.28 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $7,079.46
| Professional | | $3,311.31 | $4,677.35 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $977.24
| Professional | | $891.25 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $41,686.94
| Facility | | $3,548.13 | $3,548.13 | $41,686.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,495.41 / $5,495.41
| Facility | | $2,290.87 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $7,585.78
| Professional | | $2,290.87 | $2,754.23 | $7,585.78 |