- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $9,549.93 / $16,595.87
| Facility | | $1,949.84 | $9,549.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $9,549.93 / $16,595.87
| Professional | | $7,079.46 | $9,549.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Professional | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $1,174.90 / $1,202.26
| Facility | | $120.23 | $1,174.90 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,786.30 / $5,248.07
| Professional | | $2,398.83 | $4,786.30 | $5,248.07 |