- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,606.93 / $7,943.28
| Facility | | $4,786.30 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,778.28
| Professional | | $1,148.15 | $1,148.15 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $177.83
| Professional | | $169.82 | $169.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,011.87 / $20,417.38
| Facility | | $4,677.35 | $5,011.87 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,677.35 / $20,417.38
| Professional | | $1,148.15 | $4,677.35 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $79.43 / $79.43
| Professional | | $70.79 | $79.43 | $79.43 |