- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,324.01 / $4,081.18 / $9,645.53
| Facility | | $2,324.01 | $4,081.18 | $9,645.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.93 / $4,251.32 / $4,251.32
| Professional | | $1,751.93 | $4,251.32 | $4,251.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.60 / $950.60 / $950.60
| Professional | | $950.60 | $950.60 | $950.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,293.00 / $12,216.00 / $19,066.00
| Facility | | $5,293.00 | $12,216.00 | $19,066.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,160.00 / $10,160.00 / $10,160.00
| Facility | | $10,160.00 | $10,160.00 | $10,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.34 / $2,962.84 / $2,962.84
| Professional | | $2,014.34 | $2,962.84 | $2,962.84 |