- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,854.25 / $3,854.25 / $3,854.25
| Facility | | $3,854.25 | $3,854.25 | $3,854.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.66 / $187.66 / $271.86
| Professional | | $187.66 | $187.66 | $271.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.00 / $470.00 / $626.00
| Professional | | $325.00 | $470.00 | $626.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.72 / $337.57 / $490.40
| Professional | | $230.72 | $337.57 | $490.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.33 / $473.37 / $840.18
| Professional | | $283.33 | $473.37 | $840.18 |