- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.20 / $215.20 / $475.23
| Professional | | $215.20 | $215.20 | $475.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,280.68 / $5,974.25 / $7,146.96
| Facility | | $4,280.68 | $5,974.25 | $7,146.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.91 / $342.18 / $509.90
| Professional | | $249.91 | $342.18 | $509.90 |