- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,934.93 / $7,783.81 / $12,386.87
| Facility | | $4,934.93 | $7,783.81 | $12,386.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.99 / $4,000.00 / $14,587.03
| Facility | | $801.99 | $4,000.00 | $14,587.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.78 / $828.71 / $4,498.75
| Professional | | $576.78 | $828.71 | $4,498.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,113.60 / $4,113.60 / $4,113.60
| Facility | | $4,113.60 | $4,113.60 | $4,113.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.27 / $729.27 / $1,079.38
| Professional | | $550.27 | $729.27 | $1,079.38 |