- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.13 / $5,909.48 / $15,697.34
| Facility | | $1,996.13 | $5,909.48 | $15,697.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.52 / $380.52 / $680.00
| Professional | | $380.52 | $380.52 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,350.61 / $4,406.97 / $8,524.51
| Facility | | $3,350.61 | $4,406.97 | $8,524.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.62 / $1,242.00 / $4,406.00
| Facility | | $298.62 | $1,242.00 | $4,406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,365.04 / $2,365.04 / $2,365.04
| Professional | | $2,365.04 | $2,365.04 | $2,365.04 |
- 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 |