- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $7,585.78
| Facility | | $2,398.83 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $549.54
| Professional | | $204.17 | $302.00 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,818.38
| Professional | | $2,290.87 | $2,290.87 | $2,818.38 |