- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $7,943.28
| Facility | | $4,265.80 | $4,897.79 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,786.30 / $5,495.41
| Professional | | $3,090.30 | $4,786.30 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $9,772.37 / $9,772.37
| Professional | | $1,862.09 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $70.79
| Professional | | $50.12 | $50.12 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,309.57 / $6,309.57
| Facility | | $4,677.35 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,772.37 / $9,772.37
| Professional | | $6,025.60 | $9,772.37 | $9,772.37 |