- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,623.41 / $8,912.51
| Facility | | $4,786.30 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,715.35 / $4,786.30
| Professional | | $3,235.94 | $3,715.35 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $9,772.37 / $9,772.37
| Professional | | $2,951.21 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $11,481.54 / $11,481.54
| Facility | | $7,762.47 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,772.37 / $9,772.37
| Professional | | $5,623.41 | $9,772.37 | $9,772.37 |