- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $2,290.87
| Facility | | $1,412.54 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $5,011.87
| Professional | | $1,380.38 | $2,344.23 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $32,359.37
| Facility | | $8,511.38 | $8,511.38 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $2,398.83
| Professional | | $776.25 | $1,148.15 | $2,398.83 |