- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $9,772.37 / $10,964.78
| Facility | | $8,511.38 | $9,772.37 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $346.74 / $588.84
| Professional | | $208.93 | $346.74 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,137.96
| Professional | | $851.14 | $1,348.96 | $2,137.96 |