- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,174.00 / $4,002.00 / $6,183.00
| Facility | | $2,174.00 | $4,002.00 | $6,183.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.84 / $714.54 / $1,176.36
| Professional | | $522.84 | $714.54 | $1,176.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.07 / $11,028.25 / $11,028.25
| Facility | | $1,610.07 | $11,028.25 | $11,028.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,443.79 / $3,443.79 / $3,645.44
| Professional | | $3,443.79 | $3,443.79 | $3,645.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.52 / $824.33 / $1,205.52
| Professional | | $520.52 | $824.33 | $1,205.52 |