- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,456.54 / $28,183.83
| Facility | | $4,265.80 | $6,456.54 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $2,754.23 / $4,677.35
| Professional | | $954.99 | $2,754.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,748.98 / $15,848.93
| Facility | | $7,413.10 | $11,748.98 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $9,332.54 / $15,848.93
| Facility | | $4,168.69 | $9,332.54 | $15,848.93 |