- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $134.90 / $173.78
| Professional | | $89.13 | $134.90 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $416.87 / $1,318.26
| Facility | | $100.00 | $416.87 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $154.88 / $245.47
| Professional | | $120.23 | $154.88 | $245.47 |