- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,995.26
| Professional | | $691.83 | $812.83 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,445.44
| Professional | | $602.56 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Facility | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $831.76 / $1,380.38
| Professional | | $660.69 | $831.76 | $1,380.38 |