- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,815.85 / $9,848.64 / $22,646.38
| Facility | | $7,815.85 | $9,848.64 | $22,646.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $402.32
| Professional | | $402.32 | $402.32 | $402.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $20.01 | $20.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,917.13 / $8,444.50 / $19,130.74
| Facility | | $4,917.13 | $8,444.50 | $19,130.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $867.84
| Professional | | $402.32 | $402.32 | $867.84 |