- 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
- $446.68 / $512.86 / $1,288.25
| Professional | | $446.68 | $512.86 | $1,288.25 |
- 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
- $389.05 / $478.63 / $912.01
| Professional | | $389.05 | $478.63 | $912.01 |
- 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
- $407.38 / $501.19 / $812.83
| Professional | | $407.38 | $501.19 | $812.83 |