- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,338.26 / $4,296.89 / $6,039.66
| Facility | | $2,338.26 | $4,296.89 | $6,039.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.20 / $835.64 / $1,016.14
| Professional | | $675.20 | $835.64 | $1,016.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.12 / $3,937.84 / $5,442.62
| Facility | | $2,050.12 | $3,937.84 | $5,442.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.51 / $668.51 / $909.18
| Professional | | $668.51 | $668.51 | $909.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.39 / $3,102.50 / $13,687.50
| Facility | | $914.39 | $3,102.50 | $13,687.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,037.50 / $10,037.50 / $10,037.50
| Professional | | $10,037.50 | $10,037.50 | $10,037.50 |