- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,454.71 / $6,456.54
| Facility | | $891.25 | $2,454.71 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $549.54
| Professional | | $512.86 | $512.86 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $4,365.16
| Facility | | $1,258.93 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $323.59 / $630.96
| Professional | | $213.80 | $323.59 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,398.83
| Facility | | $1,995.26 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,466.84 / $4,466.84
| Professional | | $2,754.23 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |