- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $6,025.60
| Facility | | $1,698.24 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,897.79 / $7,413.10
| Professional | | $4,168.69 | $4,897.79 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $562.34
| Facility | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,025.60 / $8,317.64
| Professional | | $4,265.80 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $8,709.64
| Professional | | $4,073.80 | $5,495.41 | $8,709.64 |