- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,916.60 / $3,354.09 / $5,833.20
| Facility | | $2,916.60 | $3,354.09 | $5,833.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.69 / $515.80 / $1,892.44
| Professional | | $424.69 | $515.80 | $1,892.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.87 / $2,369.73 / $6,312.98
| Facility | | $1,857.87 | $2,369.73 | $6,312.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.28 / $2,333.28 / $2,333.28
| Professional | | $2,333.28 | $2,333.28 | $2,333.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,224.97 / $2,916.60
| Professional | | $1,224.97 | $1,224.97 | $2,916.60 |