- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $5,495.41
| Facility | | $1,995.26 | $1,995.26 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $549.54 / $691.83
| Professional | | $426.58 | $549.54 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $4,570.88
| Facility | | $1,348.96 | $1,513.56 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $741.31
| Professional | | $512.86 | $512.86 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $3,467.37
| Facility | | $1,288.25 | $2,454.71 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,513.56
| Professional | | $794.33 | $794.33 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $794.33
| Professional | | $467.74 | $467.74 | $794.33 |