- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,754.40 / $7,585.78
| Facility | | $5,011.87 | $5,754.40 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,365.16 / $5,754.40
| Professional | | $3,019.95 | $4,365.16 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $10,715.19
| Facility | | $3,235.94 | $4,073.80 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,466.84 / $5,011.87
| Facility | | $2,089.30 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,019.95
| Professional | | $2,089.30 | $2,089.30 | $3,019.95 |