- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,128.61 / $8,912.51
| Facility | | $1,318.26 | $5,128.61 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,888.44 / $8,912.51
| Professional | | $1,318.26 | $5,888.44 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $8,511.38
| Facility | | $2,454.71 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,691.53
| Facility | | $676.08 | $1,479.11 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Professional | | $72.44 | $72.44 | $72.44 |