- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,456.54 / $12,589.25
| Facility | | $3,467.37 | $6,456.54 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $8,511.38 / $16,982.44
| Facility | | $1,548.82 | $8,511.38 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $3,019.95
| Professional | | $0.02 | $0.02 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |