- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,398.83
| Facility | | $1,258.93 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $338.84 / $602.56
| Professional | | $208.93 | $338.84 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $6,456.54
| Facility | | $3,981.07 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $478.63
| Professional | | $204.17 | $302.00 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $331.13 / $758.58
| Professional | | $204.17 | $331.13 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,951.21 / $4,168.69
| Facility | | $812.83 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $281.84 / $478.63
| Professional | | $173.78 | $281.84 | $478.63 |