- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.88 / $1,768.13 / $1,768.13
| Facility | | $985.88 | $1,768.13 | $1,768.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.62 / $265.19 / $1,157.09
| Professional | | $175.62 | $265.19 | $1,157.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $697.00 / $2,379.00
| Professional | | $450.00 | $697.00 | $2,379.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.30 / $418.53 / $1,267.20
| Professional | | $238.30 | $418.53 | $1,267.20 |
- 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
- $283.79 / $741.83 / $1,817.82
| Professional | | $283.79 | $741.83 | $1,817.82 |