- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,786.30 / $7,244.36
| Facility | | $1,230.27 | $4,786.30 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $4,073.80 / $5,623.41
| Professional | | $691.83 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,265.80 / $12,882.50
| Facility | | $1,023.29 | $4,265.80 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $7,585.78 / $10,232.93
| Professional | | $1,584.89 | $7,585.78 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $10,232.93 / $15,848.93
| Facility | | $4,677.35 | $10,232.93 | $15,848.93 |