- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,120.11 / $43,651.58
| Facility | | $6,025.60 | $9,120.11 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,019.95
| Facility | | $2,398.83 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,570.40 / $3,019.95
| Professional | | $2,398.83 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,398.83 / $5,011.87
| Facility | | $2,238.72 | $2,398.83 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,951.21
| Professional | | $2,511.89 | $2,511.89 | $2,951.21 |