- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $9,549.93
| Facility | | $3,162.28 | $6,309.57 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $741.31
| Professional | | $660.69 | $660.69 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,302.69 / $13,803.84
| Facility | | $7,413.10 | $12,302.69 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $208.93 / $691.83
| Professional | | $177.83 | $208.93 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |