- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,025.60
| Facility | | $4,786.30 | $4,786.30 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $524.81 / $1,862.09
| Professional | | $257.04 | $524.81 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,691.53
| Facility | | $2,570.40 | $2,570.40 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $851.14 / $851.14
| Professional | | $831.76 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $380.19 / $812.83
| Professional | | $223.87 | $380.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $512.86 / $1,096.48
| Professional | | $288.40 | $512.86 | $1,096.48 |