- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $1,737.80
| Facility | | $933.25 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $691.83
| Professional | | $389.05 | $602.56 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $58.88 / $70.79
| Professional | | $50.12 | $58.88 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $6,456.54
| Facility | | $4,365.16 | $4,365.16 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,548.82 / $1,548.82
| Professional | | $870.96 | $1,548.82 | $1,548.82 |