- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $10,471.29
| Facility | | $8,128.31 | $8,128.31 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,318.26 / $4,786.30
| Professional | | $354.81 | $1,318.26 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,466.84 / $7,943.28
| Facility | | $4,265.80 | $4,466.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $562.34 / $3,630.78
| Professional | | $489.78 | $562.34 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,445.44 / $4,466.84
| Professional | | $446.68 | $1,445.44 | $4,466.84 |