- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.10 / $9,914.29 / $12,977.92
| Facility | | $1,210.10 | $9,914.29 | $12,977.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.40 / $410.52 / $1,095.92
| Professional | | $408.40 | $410.52 | $1,095.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.66 / $1,318.66 / $1,318.66
| Facility | | $1,318.66 | $1,318.66 | $1,318.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.48 / $493.58 / $865.02
| Professional | | $415.48 | $493.58 | $865.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,394.43 / $5,394.43 / $8,169.59
| Facility | | $5,394.43 | $5,394.43 | $8,169.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Facility | | $1,485.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.13 / $529.75 / $1,073.73
| Professional | | $397.13 | $529.75 | $1,073.73 |