- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,897.79
| Facility | | $2,041.74 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $1,023.29 / $1,258.93
| Professional | | $223.87 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $549.54
| Facility | | $346.74 | $346.74 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $549.54 / $549.54
| Professional | | $104.71 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,897.79 / $7,762.47
| Facility | | $2,041.74 | $4,897.79 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $2,691.53 / $3,630.78
| Professional | | $549.54 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,073.80 / $6,309.57
| Facility | | $1,230.27 | $4,073.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,818.38 / $3,467.37
| Professional | | $1,096.48 | $2,818.38 | $3,467.37 |