- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,090.30 / $3,090.30
| Facility | | $1,995.26 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $478.63 / $562.34
| Professional | | $457.09 | $478.63 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,479.11 / $1,659.59
| Facility | | $0.02 | $1,479.11 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $416.87 / $1,000.00
| Professional | | $288.40 | $416.87 | $1,000.00 |