- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,801.89 / $8,912.51
| Facility | | $1,202.26 | $3,801.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $1,819.70
| Professional | | $1,621.81 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,762.47 / $9,332.54
| Facility | | $6,025.60 | $7,762.47 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,265.80 / $7,585.78
| Facility | | $1,288.25 | $4,265.80 | $7,585.78 |