- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.08 / $2,638.58 / $4,520.46
| Facility | | $1,675.08 | $2,638.58 | $4,520.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $400.00 / $425.63
| Professional | | $318.75 | $400.00 | $425.63 |
- 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
- $1,079.31 / $1,079.31 / $1,079.31
| Professional | | $1,079.31 | $1,079.31 | $1,079.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,322.82 / $1,322.82 / $1,322.82
| Facility | | $1,322.82 | $1,322.82 | $1,322.82 |