- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,380.38 / $2,238.72
| Professional | | $398.11 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,918.31 / $9,332.54
| Facility | | $5,754.40 | $6,918.31 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,380.38 / $2,290.87
| Professional | | $457.09 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $794.33 / $2,754.23
| Professional | | $426.58 | $794.33 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,606.93
| Facility | | $1,479.11 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,318.26 / $2,511.89
| Professional | | $371.54 | $1,318.26 | $2,511.89 |