- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $4,897.79
| Facility | | $2,884.03 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $346.74 / $489.78
| Professional | | $269.15 | $346.74 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,698.24 / $1,698.24
| Professional | | $1,621.81 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,884.03 / $4,897.79
| Facility | | $489.78 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $457.09 / $616.60
| Professional | | $346.74 | $457.09 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,235.94 / $6,025.60
| Facility | | $1,445.44 | $3,235.94 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $575.44 / $741.31
| Professional | | $457.09 | $575.44 | $741.31 |