- 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
- $1,238.47 / $2,162.54 / $2,162.54
| Professional | | $1,238.47 | $2,162.54 | $2,162.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,418.01 / $9,419.70 / $11,134.41
| Facility | | $8,418.01 | $9,419.70 | $11,134.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.96 / $1,920.84 / $4,599.57
| Professional | | $971.96 | $1,920.84 | $4,599.57 |