- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $6,456.54 / $12,589.25
| Facility | | $645.65 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,165.95 / $12,022.64
| Facility | | $4,677.35 | $6,165.95 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $660.69 / $4,073.80
| Facility | | $389.05 | $660.69 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,445.44
| Professional | | $707.95 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $8,128.31
| Facility | | $3,630.78 | $4,897.79 | $8,128.31 |