- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,307.74 / $5,562.52 / $8,074.62
| Professional | | $4,307.74 | $5,562.52 | $8,074.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.66 / $150.66 / $150.66
| Facility | | $150.66 | $150.66 | $150.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,406.39 / $5,406.39 / $5,406.39
| Professional | | $5,406.39 | $5,406.39 | $5,406.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $4,321.80 / $4,321.80
| Facility | | $775.57 | $4,321.80 | $4,321.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.15 / $4,321.80 / $14,850.00
| Professional | | $724.15 | $4,321.80 | $14,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.07 / $3,272.55 / $4,668.84
| Professional | | $1,931.07 | $3,272.55 | $4,668.84 |