- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,897.79
| Facility | | $4,073.80 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $257.04 / $630.96
| Professional | | $173.78 | $257.04 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $3,388.44
| Professional | | $2,137.96 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $4,073.80 / $5,754.40
| Facility | | $588.84 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $263.03 / $616.60
| Professional | | $218.78 | $263.03 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,025.60 / $9,772.37
| Facility | | $2,884.03 | $6,025.60 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $323.59 / $831.76
| Professional | | $251.19 | $323.59 | $831.76 |