- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,481.54 / $18,197.01
| Facility | | $5,370.32 | $11,481.54 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,949.84
| Professional | | $1,096.48 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,481.54 / $18,197.01
| Facility | | $5,370.32 | $11,481.54 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,041.74
| Professional | | $1,096.48 | $1,096.48 | $2,041.74 |