- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,801.89 / $6,606.93
| Facility | | $1,288.25 | $3,801.89 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $6,309.57
| Professional | | $3,235.94 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,079.46 / $11,481.54
| Facility | | $4,466.84 | $7,079.46 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $1,318.26 / $2,691.53
| Facility | | $223.87 | $1,318.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,318.26 / $2,630.27
| Facility | | $354.81 | $1,318.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | | $436.52 | $436.52 | $436.52 |