- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,739.33 / $7,885.02 / $13,478.70
| Facility | | $6,739.33 | $7,885.02 | $13,478.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,728.43 / $7,885.02 / $7,885.02
| Professional | | $5,728.43 | $7,885.02 | $7,885.02 |
- 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 / $4,372.81
| Professional | | $424.69 | $515.80 | $4,372.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,380.56 / $5,475.70 / $14,587.26
| Facility | | $4,380.56 | $5,475.70 | $14,587.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $2,830.52 / $4,043.60
| Professional | | $2,830.52 | $2,830.52 | $4,043.60 |