- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.20 / $2,562.00 / $3,884.00
| Facility | | $435.20 | $2,562.00 | $3,884.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.20 / $415.84 / $474.05
| Professional | | $270.20 | $415.84 | $474.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.27 / $2,389.87 / $3,567.80
| Facility | | $1,137.27 | $2,389.87 | $3,567.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.00 / $1,261.00 / $7,168.00
| Facility | | $385.00 | $1,261.00 | $7,168.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.48 / $539.36 / $882.96
| Professional | | $375.48 | $539.36 | $882.96 |