- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,943.28 / $7,943.28
| Facility | | $5,011.87 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,445.44
| Professional | | $1,148.15 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,511.89
| Professional | | $741.31 | $1,047.13 | $2,511.89 |