- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,244.36 / $9,549.93
| Facility | | $6,025.60 | $7,244.36 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $630.96 / $1,584.89
| Professional | | $549.54 | $630.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $645.65 / $1,122.02
| Professional | | $478.63 | $645.65 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $630.96 / $1,000.00
| Professional | | $501.19 | $630.96 | $1,000.00 |