- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,344.23 / $3,630.78
| Facility | | $1,071.52 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $7,943.28 / $12,882.50
| Professional | | $478.63 | $7,943.28 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $25,703.96
| Facility | | $18,620.87 | $18,620.87 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $23,988.33
| Facility | | $3,715.35 | $7,762.47 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $870.96 / $12,882.50
| Professional | | $630.96 | $870.96 | $12,882.50 |