- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $2,761.00 / $4,100.00
| Facility | | $1,017.00 | $2,761.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.24 / $62.24 / $62.24
| Professional | | $62.24 | $62.24 | $62.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.30 / $135.07 / $135.07
| Professional | | $95.30 | $135.07 | $135.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $665.00 / $762.00 / $6,342.00
| Facility | | $665.00 | $762.00 | $6,342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.60 / $87.68 / $1,584.33
| Professional | | $36.60 | $87.68 | $1,584.33 |