- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,309.57 / $10,471.29
| Facility | | $3,162.28 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,265.80
| Professional | | $3,162.28 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $3,162.28 / $4,897.79
| Facility | | $467.74 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42,657.95 / $42,657.95 / $42,657.95
| Professional | | $42,657.95 | $42,657.95 | $42,657.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $5,623.41
| Facility | | $776.25 | $1,230.27 | $5,623.41 |