- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,695.08 / $1,695.08 / $1,695.08
| Facility | | $1,695.08 | $1,695.08 | $1,695.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.52 / $154.91 / $1,056.83
| Professional | | $79.52 | $154.91 | $1,056.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.00 / $318.00 / $754.00
| Professional | | $206.00 | $318.00 | $754.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.56 / $188.83 / $385.81
| Professional | | $112.56 | $188.83 | $385.81 |
- 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
- $190.20 / $306.82 / $620.41
| Professional | | $190.20 | $306.82 | $620.41 |