- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $8,128.31
| Facility | | $4,677.35 | $4,677.35 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64,565.42 / $83,176.38 / $95,499.26
| Facility | | $64,565.42 | $83,176.38 | $95,499.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $8,912.51
| Facility | | $4,786.30 | $5,248.07 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $85.11
| Professional | | $79.43 | $79.43 | $85.11 |