- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,784.53 / $7,928.26 / $12,162.16
| Facility | | $6,784.53 | $7,928.26 | $12,162.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.13 / $2,678.75 / $3,158.91
| Professional | | $2,527.13 | $2,678.75 | $3,158.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,874.42 / $3,874.42 / $3,874.42
| Facility | | $3,874.42 | $3,874.42 | $3,874.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.00 / $2,698.21 / $3,874.42
| Facility | | $70.00 | $2,698.21 | $3,874.42 |