- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,166.29 / $5,628.36 / $13,841.56
| Facility | | $2,166.29 | $5,628.36 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.33 / $115.33 / $115.33
| Professional | | $115.33 | $115.33 | $115.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,070.46 / $5,901.02 / $10,355.91
| Facility | | $4,070.46 | $5,901.02 | $10,355.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $714.50 / $1,518.86 / $6,043.00
| Facility | | $714.50 | $1,518.86 | $6,043.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.00 / $3,227.00 / $6,169.00
| Facility | | $1,775.00 | $3,227.00 | $6,169.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $68.73 / $84.10
| Professional | | $68.73 | $68.73 | $84.10 |