- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,370.32 / $7,413.10
| Facility | | $2,041.74 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $602.56
| Professional | | $512.86 | $512.86 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,388.44 / $6,918.31
| Facility | | $1,230.27 | $3,388.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,071.52
| Professional | | $912.01 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $537.03 / $1,778.28
| Professional | | $239.88 | $537.03 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,290.87 / $2,290.87
| Professional | | $741.31 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |