- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,801.89 / $12,589.25
| Facility | | $933.25 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $12,882.50
| Facility | | $5,128.61 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $707.95 / $4,265.80
| Facility | | $269.15 | $707.95 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,318.26
| Professional | | $676.08 | $954.99 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,365.16 / $8,128.31
| Facility | | $2,951.21 | $4,365.16 | $8,128.31 |