- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.66 / $2,387.66 / $2,387.66
| Facility | | $2,387.66 | $2,387.66 | $2,387.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.78 / $141.37 / $283.87
| Professional | | $87.78 | $141.37 | $283.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.00 / $352.00 / $1,061.00
| Professional | | $227.00 | $352.00 | $1,061.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.80 / $250.89 / $497.50
| Professional | | $129.80 | $250.89 | $497.50 |
- 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
- $208.96 / $413.40 / $861.98
| Professional | | $208.96 | $413.40 | $861.98 |