- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,659.05 / $2,659.05 / $2,659.05
| Facility | | $2,659.05 | $2,659.05 | $2,659.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.72 / $282.55 / $935.44
| Professional | | $189.72 | $282.55 | $935.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.00 / $488.00 / $576.00
| Professional | | $432.00 | $488.00 | $576.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.07 / $364.21 / $515.02
| Professional | | $273.07 | $364.21 | $515.02 |
- 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
- $324.95 / $716.01 / $1,144.46
| Professional | | $324.95 | $716.01 | $1,144.46 |