- 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
- $234.42 / $346.74 / $407.38
| Professional | | $234.42 | $346.74 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $3,388.44
| Facility | | $2,137.96 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,388.44 / $3,388.44
| Professional | | $2,041.74 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $4,073.80 / $5,754.40
| Facility | | $416.87 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $389.05 / $524.81
| Professional | | $338.84 | $389.05 | $524.81 |
- 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
- $389.05 / $478.63 / $660.69
| Professional | | $389.05 | $478.63 | $660.69 |