- 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
- $776.25 / $912.01 / $2,187.76
| Professional | | $776.25 | $912.01 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,584.89
| Professional | | $691.83 | $912.01 | $1,584.89 |
- 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
- $724.44 / $851.14 / $1,412.54
| Professional | | $724.44 | $851.14 | $1,412.54 |