- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,786.30 / $4,786.30
| Facility | | $2,344.23 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,309.57 / $12,302.69
| Facility | | $4,897.79 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $13,803.84
| Facility | | $2,344.23 | $3,715.35 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,128.61 / $6,760.83
| Professional | | $4,073.80 | $5,128.61 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $467.74 / $1,659.59
| Facility | | $398.11 | $467.74 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $13,803.84
| Facility | | $1,995.26 | $3,715.35 | $13,803.84 |