- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,237.25 / $3,231.90 / $4,587.20
| Facility | | $2,237.25 | $3,231.90 | $4,587.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $400.00 / $400.04
| Professional | | $318.75 | $400.00 | $400.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.90 / $770.09 / $2,397.36
| Facility | | $376.90 | $770.09 | $2,397.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.52 / $1,940.81 / $1,940.81
| Professional | | $1,561.52 | $1,940.81 | $1,940.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,501.12 / $2,169.32 / $6,437.64
| Facility | | $1,501.12 | $2,169.32 | $6,437.64 |