- 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
- $577.60 / $577.60 / $603.95
| Professional | | $577.60 | $577.60 | $603.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,041.10 / $7,951.93 / $8,835.48
| Facility | | $6,041.10 | $7,951.93 | $8,835.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $9,764.00
| Facility | | $3,599.00 | $7,228.00 | $9,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.36 / $1,404.45 / $2,041.14
| Professional | | $826.36 | $1,404.45 | $2,041.14 |