- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,265.80 / $4,265.80
| Facility | | $2,754.23 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $660.69 / $776.25
| Professional | | $630.96 | $660.69 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $2,818.38
| Facility | | $1,659.59 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $602.56 / $707.95
| Professional | | $501.19 | $602.56 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $575.44 / $1,380.38
| Professional | | $398.11 | $575.44 | $1,380.38 |