- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $2,454.71
| Professional | | $371.54 | $371.54 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $9,772.37 / $10,964.78
| Facility | | $8,511.38 | $9,772.37 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,454.71
| Professional | | $1,174.90 | $1,584.89 | $2,454.71 |