- 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
- $389.05 / $436.52 / $1,071.52
| Professional | | $389.05 | $436.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $407.38 / $776.25
| Professional | | $354.81 | $407.38 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $15,848.93
| Facility | | $6,025.60 | $6,025.60 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $426.58 / $676.08
| Professional | | $346.74 | $426.58 | $676.08 |