- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.58 / $10,725.33 / $12,674.87
| Facility | | $2,578.58 | $10,725.33 | $12,674.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.72 / $964.70 / $1,129.33
| Professional | | $904.72 | $964.70 | $1,129.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.76 / $3,200.76 / $3,200.76
| Facility | | $3,200.76 | $3,200.76 | $3,200.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.21 / $1,008.77 / $2,021.61
| Professional | | $865.21 | $1,008.77 | $2,021.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,884.85 / $7,884.85 / $12,244.77
| Facility | | $7,884.85 | $7,884.85 | $12,244.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.33 / $1,125.02 / $2,380.19
| Professional | | $880.33 | $1,125.02 | $2,380.19 |