- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.12 / $1,988.12 / $2,485.15
| Professional | | $1,988.12 | $1,988.12 | $2,485.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.87 / $1,257.66 / $3,190.88
| Facility | | $142.87 | $1,257.66 | $3,190.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.87 / $7,524.00 / $7,524.00
| Professional | | $990.87 | $7,524.00 | $7,524.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.00 / $1,591.00 / $1,591.00
| Facility | | $1,591.00 | $1,591.00 | $1,591.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.00 / $1,587.50 / $1,600.16
| Professional | | $1,294.00 | $1,587.50 | $1,600.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.59 / $1,174.59 / $1,473.90
| Professional | | $1,174.59 | $1,174.59 | $1,473.90 |