- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,454.71 / $6,456.54
| Facility | | $891.25 | $2,454.71 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $501.19 / $645.65
| Professional | | $338.84 | $501.19 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,073.80 / $5,888.44
| Facility | | $1,621.81 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $1,174.90
| Professional | | $562.34 | $758.58 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Facility | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $4,073.80
| Professional | | $3,388.44 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,570.88 / $7,585.78
| Facility | | $2,754.23 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $776.25 / $1,202.26
| Professional | | $501.19 | $776.25 | $1,202.26 |