- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $3,548.13
| Facility | | $1,905.46 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,238.72 / $2,570.40
| Professional | | $1,174.90 | $2,238.72 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Professional | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $54.95 / $70.79
| Professional | | $50.12 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,623.41 / $5,623.41
| Facility | | $3,890.45 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $6,165.95 / $6,165.95
| Professional | | $2,691.53 | $6,165.95 | $6,165.95 |