- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $6,472.83 / $6,907.00
| Facility | | $4,736.00 | $6,472.83 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.30 / $413.89 / $981.57
| Professional | | $325.30 | $413.89 | $981.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.02 / $623.04 / $1,508.90
| Professional | | $310.02 | $623.04 | $1,508.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,130.85 / $5,130.85 / $6,469.26
| Facility | | $5,130.85 | $5,130.85 | $6,469.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.50 / $924.94 / $2,105.94
| Professional | | $674.50 | $924.94 | $2,105.94 |