- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,570.05 / $2,738.70 / $4,458.75
| Facility | | $1,570.05 | $2,738.70 | $4,458.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.13 / $5,970.75 / $5,970.75
| Professional | | $928.13 | $5,970.75 | $5,970.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.00 / $917.00 / $1,100.00
| Professional | | $917.00 | $917.00 | $1,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.05 / $739.72 / $1,025.28
| Professional | | $547.05 | $739.72 | $1,025.28 |
- 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
- $615.45 / $1,035.84 / $1,673.77
| Professional | | $615.45 | $1,035.84 | $1,673.77 |