- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,235.94
| Facility | | $2,089.30 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,818.38
| Professional | | $1,023.29 | $1,023.29 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $3,090.30 / $4,677.35
| Facility | | $1.00 | $3,090.30 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $3,630.78
| Professional | | $2,398.83 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |