- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,511.38 / $8,511.38
| Facility | | $2,818.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $6,918.31 / $8,709.64
| Professional | | $501.19 | $6,918.31 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $13,803.84 / $16,982.44
| Professional | | $831.76 | $13,803.84 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,548.82
| Professional | | $741.31 | $1,071.52 | $1,548.82 |