- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,570.88 / $9,549.93
| Professional | | $1,071.52 | $4,570.88 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $5,011.87
| Facility | | $1,096.48 | $1,995.26 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $2,630.27
| Professional | | $1,737.80 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,344.23 / $3,981.07
| Facility | | $602.56 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $9,120.11 / $13,489.63
| Professional | | $2,041.74 | $9,120.11 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,238.72 / $5,495.41
| Facility | | $741.31 | $2,238.72 | $5,495.41 |