- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,115.58 / $3,572.53 / $3,697.15
| Facility | | $3,115.58 | $3,572.53 | $3,697.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.57 / $3,572.53 / $3,890.21
| Professional | | $2,780.57 | $3,572.53 | $3,890.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.03
| Facility | | $0.02 | $0.03 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.91 / $3,175.96 / $3,252.40
| Professional | | $2,705.91 | $3,175.96 | $3,252.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $6,067.50
| Professional | | $248.35 | $248.35 | $6,067.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $249.25 / $2,172.39
| Professional | | $151.16 | $249.25 | $2,172.39 |