- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $12,302.69 / $13,489.63
| Facility | | $6,760.83 | $12,302.69 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,495.41 / $12,302.69
| Professional | | $5,011.87 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $9,120.11 / $9,120.11
| Facility | | $8,709.64 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $8,128.31
| Facility | | $6,025.60 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,073.80 / $15,135.61
| Professional | | $2,818.38 | $4,073.80 | $15,135.61 |