- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,633.36 / $7,633.36 / $7,633.36
| Facility | | $7,633.36 | $7,633.36 | $7,633.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.16 / $160.16 / $256.36
| Professional | | $160.16 | $160.16 | $256.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.00 / $423.00 / $667.00
| Professional | | $290.00 | $423.00 | $667.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.09 / $328.61 / $582.92
| Professional | | $212.09 | $328.61 | $582.92 |
- 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
- $358.05 / $554.79 / $1,000.58
| Professional | | $358.05 | $554.79 | $1,000.58 |