- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,786.30 / $37,153.52
| Facility | | $4,466.84 | $4,786.30 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $4,466.84
| Professional | | $3,548.13 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $398.11 / $831.76
| Professional | | $128.82 | $398.11 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $18,620.87
| Professional | | $18,620.87 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Professional | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $6,309.57
| Professional | | $3,548.13 | $3,715.35 | $6,309.57 |