- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,244.36 / $9,549.93
| Facility | | $4,897.79 | $7,244.36 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $1,819.70
| Professional | | $676.08 | $794.33 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $794.33 / $1,380.38
| Professional | | $575.44 | $794.33 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,258.93
| Professional | | $630.96 | $758.58 | $1,258.93 |