- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,570.88 / $5,128.61
| Facility | | $2,511.89 | $4,570.88 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,041.74 / $4,570.88
| Professional | | $1,862.09 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,698.24 / $2,137.96
| Facility | | $1,621.81 | $1,698.24 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,511.89 / $3,019.95
| Facility | | $2,238.72 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $6,165.95
| Professional | | $1,047.13 | $1,513.56 | $6,165.95 |