- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $2,238.72
| Facility | | $1,230.27 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $17,378.01 / $21,379.62
| Facility | | $17,378.01 | $17,378.01 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $24,547.09 / $38,018.94
| Facility | | $15,488.17 | $24,547.09 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $89.13 / $89.13
| Professional | | $75.86 | $89.13 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $25,703.96 / $30,902.95
| Facility | | $14,125.38 | $25,703.96 | $30,902.95 |