- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,365.16 / $7,244.36
| Facility | | $4,073.80 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $1,584.89
| Professional | | $549.54 | $616.60 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $630.96 / $1,122.02
| Professional | | $467.74 | $630.96 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $630.96 / $1,047.13
| Professional | | $512.86 | $630.96 | $1,047.13 |