- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.13 / $5,909.48 / $13,841.56
| Facility | | $2,834.13 | $5,909.48 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.00 / $1,556.10 / $11,100.08
| Professional | | $779.00 | $1,556.10 | $11,100.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,906.94 / $7,769.24 / $15,028.22
| Facility | | $5,906.94 | $7,769.24 | $15,028.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.00 / $1,775.00 / $4,406.00
| Facility | | $1,242.00 | $1,775.00 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $68.73 / $84.10
| Professional | | $68.73 | $68.73 | $84.10 |