- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $4,897.79
| Facility | | $4,073.80 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $5,754.40
| Facility | | $4,073.80 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,606.93 / $9,332.54
| Professional | | $6,165.95 | $6,606.93 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,786.30 / $10,232.93
| Facility | | $1,445.44 | $4,786.30 | $10,232.93 |