- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $8,005.65 / $9,606.78
| Facility | | $4,736.00 | $8,005.65 | $9,606.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.51 / $842.51 / $965.66
| Professional | | $842.51 | $842.51 | $965.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.07 / $1,171.11 / $1,658.22
| Professional | | $858.07 | $1,171.11 | $1,658.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,013.96 / $11,013.96 / $11,013.96
| Facility | | $11,013.96 | $11,013.96 | $11,013.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.99 / $1,134.68 / $2,153.83
| Professional | | $893.99 | $1,134.68 | $2,153.83 |