- 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
- $172.97 / $192.80 / $348.81
| Professional | | $172.97 | $192.80 | $348.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,387.61 / $8,356.70 / $10,218.25
| Facility | | $5,387.61 | $8,356.70 | $10,218.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.78 / $406.29 / $604.08
| Professional | | $221.78 | $406.29 | $604.08 |