- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,311.31 / $8,709.64
| Facility | | $2,041.74 | $3,311.31 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $15,488.17
| Facility | | $602.56 | $602.56 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,897.79
| Professional | | $3,467.37 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $4,265.80
| Facility | | $2,041.74 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,890.45 / $6,918.31
| Facility | | $1,047.13 | $3,890.45 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $26,302.68 / $26,302.68
| Facility | | $5,011.87 | $26,302.68 | $26,302.68 |