- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $2,691.53
| Facility | | $1,348.96 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $2,454.71
| Professional | | $891.25 | $1,047.13 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $912.01
| Facility | | $870.96 | $870.96 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $39.81 / $50.12
| Professional | | $21.38 | $39.81 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,621.81
| Facility | | $1,202.26 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $2,951.21
| Professional | | $562.34 | $794.33 | $2,951.21 |