- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.80 / $6,406.69 / $10,951.60
| Facility | | $5,475.80 | $6,406.69 | $10,951.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,654.43 / $6,406.69 / $6,406.69
| Professional | | $4,654.43 | $6,406.69 | $6,406.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $69.98 / $94.15
| Facility | | $57.67 | $69.98 | $94.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.69 / $515.80 / $3,552.97
| Professional | | $424.69 | $515.80 | $3,552.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.27 / $4,449.09 / $11,852.37
| Facility | | $3,559.27 | $4,449.09 | $11,852.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $2,299.84 / $5,475.80
| Professional | | $2,299.84 | $2,299.84 | $5,475.80 |