- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,888.44 / $9,120.11
| Facility | | $3,235.94 | $5,888.44 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $707.95 / $724.44
| Professional | | $602.56 | $707.95 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $3,548.13
| Facility | | $741.31 | $741.31 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $2,398.83
| Professional | | $741.31 | $741.31 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,754.23 / $3,019.95
| Facility | | $741.31 | $2,754.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,089.30 / $3,548.13
| Facility | | $602.56 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,513.56 / $2,238.72
| Professional | | $446.68 | $1,513.56 | $2,238.72 |