- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.54 / $4,132.83 / $4,132.83
| Facility | | $1,935.54 | $4,132.83 | $4,132.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.04 / $528.70 / $2,473.80
| Professional | | $195.04 | $528.70 | $2,473.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.00 / $776.00 / $1,986.00
| Professional | | $502.00 | $776.00 | $1,986.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.70 / $466.97 / $1,013.33
| Professional | | $268.70 | $466.97 | $1,013.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $3,793.98 / $5,606.00
| Facility | | $1,275.00 | $3,793.98 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.45 / $787.64 / $1,470.30
| Professional | | $329.45 | $787.64 | $1,470.30 |