- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,168.69 / $6,606.93
| Facility | | $3,548.13 | $4,168.69 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,621.81 / $3,162.28
| Professional | | $616.60 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $478.63 / $1,905.46
| Facility | | $338.84 | $478.63 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $1,995.26
| Facility | | $354.81 | $489.78 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,309.57 / $6,309.57
| Professional | | $2,290.87 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,677.35 / $4,677.35
| Facility | | $2,754.23 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,309.57 / $6,309.57
| Professional | | $3,981.07 | $6,309.57 | $6,309.57 |