- 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
- $512.86 / $575.44 / $1,479.11
| Professional | | $512.86 | $575.44 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $1,023.29
| Professional | | $436.52 | $575.44 | $1,023.29 |
- 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
- $467.74 / $588.84 / $954.99
| Professional | | $467.74 | $588.84 | $954.99 |