- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.53 / $2,299.62 / $2,527.06
| Facility | | $1,263.53 | $2,299.62 | $2,527.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.19 / $2,299.62 / $2,527.06
| Professional | | $998.19 | $2,299.62 | $2,527.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.59 / $1,705.77 / $1,705.77
| Facility | | $1,642.59 | $1,705.77 | $1,705.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $758.12 / $2,148.00
| Professional | | $530.67 | $758.12 | $2,148.00 |