- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.06 / $7,948.98 / $13,979.78
| Facility | | $3,183.06 | $7,948.98 | $13,979.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,765.22 / $6,144.57 / $12,272.24
| Facility | | $4,765.22 | $6,144.57 | $12,272.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,098.54 / $5,440.39 / $7,119.70
| Professional | | $4,098.54 | $5,440.39 | $7,119.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,140.00 / $4,140.00 / $4,140.00
| Facility | | $4,140.00 | $4,140.00 | $4,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $51.00
| Professional | | $30.00 | $30.00 | $51.00 |