- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.83 / $1,579.83 / $4,837.00
| Professional | | $1,579.83 | $1,579.83 | $4,837.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $806.13 / $806.13 / $806.13
| Facility | | $806.13 | $806.13 | $806.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.62 / $1,477.62 / $1,477.62
| Professional | | $1,477.62 | $1,477.62 | $1,477.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.00 / $1,064.49 / $1,596.73
| Professional | | $85.00 | $1,064.49 | $1,596.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $806.13 / $806.13 / $890.78
| Facility | | $806.13 | $806.13 | $890.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.65 / $1,116.30 / $1,741.43
| Professional | | $103.65 | $1,116.30 | $1,741.43 |