- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,456.54 / $7,244.36
| Facility | | $4,897.79 | $6,456.54 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $933.25 / $2,398.83
| Professional | | $346.74 | $933.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $616.60 / $1,548.82
| Professional | | $363.08 | $616.60 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,456.54 / $7,585.78
| Facility | | $5,128.61 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $645.65 / $1,318.26
| Professional | | $288.40 | $645.65 | $1,318.26 |