- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,779.25 / $2,779.25 / $2,779.25
| Facility | | $2,779.25 | $2,779.25 | $2,779.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.25 / $511.61 / $1,686.00
| Professional | | $131.25 | $511.61 | $1,686.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $2,675.00 / $2,675.00
| Professional | | $2,675.00 | $2,675.00 | $2,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $599.00 / $2,530.00
| Facility | | $582.00 | $599.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.00 / $108.00 / $550.00
| Facility | | $76.00 | $108.00 | $550.00 |