- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $4,168.69
| Professional | | $616.60 | $616.60 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $21,379.62 / $25,118.86
| Facility | | $15,848.93 | $21,379.62 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $23,988.33
| Facility | | $4,466.84 | $8,128.31 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $794.33 / $13,803.84
| Professional | | $426.58 | $794.33 | $13,803.84 |