- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.75 / $1,221.75 / $1,221.75
| Facility | | $1,221.75 | $1,221.75 | $1,221.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.87 / $221.30 / $1,381.25
| Professional | | $219.87 | $221.30 | $1,381.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.00 / $570.00 / $3,280.00
| Professional | | $391.00 | $570.00 | $3,280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.12 / $520.07 / $2,117.87
| Professional | | $318.12 | $520.07 | $2,117.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.05 / $2,828.09 / $3,393.73
| Professional | | $1,414.05 | $2,828.09 | $3,393.73 |