- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,120.11 / $16,595.87
| Facility | | $6,760.83 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $870.96
| Professional | | $602.56 | $741.31 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $812.83
| Professional | | $147.91 | $147.91 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,454.71 / $7,585.78
| Facility | | $2,187.76 | $2,454.71 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $954.99
| Facility | | $602.56 | $758.58 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $17,378.01 / $25,703.96
| Facility | | $2,884.03 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,380.38
| Professional | | $691.83 | $870.96 | $1,380.38 |