- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.18 / $2,398.71 / $2,596.67
| Professional | | $1,712.18 | $2,398.71 | $2,596.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.01 / $2,917.38 / $3,625.09
| Professional | | $2,410.01 | $2,917.38 | $3,625.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.00 / $173.00 / $471.00
| Facility | | $173.00 | $173.00 | $471.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.03 / $2,706.24 / $4,917.62
| Professional | | $1,933.03 | $2,706.24 | $4,917.62 |