- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,495.41 / $11,481.54
| Facility | | $4,677.35 | $5,495.41 | $11,481.54 |
- 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
- $6,606.93 / $7,413.10 / $9,332.54
| Facility | | $6,606.93 | $7,413.10 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $8,912.51
| Facility | | $4,786.30 | $6,025.60 | $8,912.51 |