- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,244.36
| Facility | | $7,079.46 | $7,079.46 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,311.31 / $13,803.84
| Professional | | $741.31 | $3,311.31 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $10,964.78
| Professional | | $794.33 | $1,380.38 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $9,332.54
| Professional | | $831.76 | $1,380.38 | $9,332.54 |