- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,079.46 / $12,589.25
| Facility | | $4,786.30 | $7,079.46 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,943.28 / $15,488.17
| Facility | | $6,025.60 | $7,943.28 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $354.81 / $4,786.30
| Facility | | $213.80 | $354.81 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $707.95
| Professional | | $457.09 | $512.86 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $8,128.31
| Facility | | $3,630.78 | $5,011.87 | $8,128.31 |