- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,248.07 / $10,471.29
| Facility | | $2,398.83 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,606.93 / $6,606.93
| Professional | | $2,398.83 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $2,630.27
| Facility | | $912.01 | $912.01 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,884.03 / $6,456.54
| Facility | | $977.24 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,884.03 / $4,677.35
| Facility | | $1,445.44 | $2,884.03 | $4,677.35 |