- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,739.33 / $12,265.60 / $13,478.70
| Facility | | $6,739.33 | $12,265.60 | $13,478.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,324.07 / $12,265.58 / $13,478.66
| Professional | | $5,324.07 | $12,265.58 | $13,478.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,761.12 / $9,098.10 / $9,098.10
| Facility | | $8,761.12 | $9,098.10 | $9,098.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $4,043.60 / $11,456.86
| Professional | | $2,830.52 | $4,043.60 | $11,456.86 |