- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,871.74 / $3,871.74 / $3,871.74
| Facility | | $3,871.74 | $3,871.74 | $3,871.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.17 / $175.34 / $392.58
| Professional | | $172.17 | $175.34 | $392.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.00 / $455.00 / $982.00
| Professional | | $312.00 | $455.00 | $982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.87 / $412.15 / $808.63
| Professional | | $257.87 | $412.15 | $808.63 |
- 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
- $585.76 / $806.96 / $1,520.63
| Professional | | $585.76 | $806.96 | $1,520.63 |