- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,388.44 / $6,025.60
| Facility | | $3,162.28 | $3,388.44 | $6,025.60 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $60.26
| Professional | | $30.20 | $44.67 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Professional | | $9,549.93 | $9,549.93 | $9,549.93 |