- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,606.93 / $14,125.38
| Facility | | $3,630.78 | $6,606.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $831.76
| Professional | | $602.56 | $602.56 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $1,905.46 / $5,370.32
| Facility | | $323.59 | $1,905.46 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,000.00 / $2,511.89
| Professional | | $389.05 | $1,000.00 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,165.95 / $14,125.38
| Facility | | $2,884.03 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $630.96 / $1,548.82
| Professional | | $194.98 | $630.96 | $1,548.82 |