- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $3,162.28
| Facility | | $776.25 | $1,819.70 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,265.80
| Professional | | $3,162.28 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $25.12 / $58.88
| Professional | | $19.95 | $25.12 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,348.96 / $4,073.80
| Facility | | $575.44 | $1,348.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $42.66 / $42.66
| Professional | | $42.66 | $42.66 | $42.66 |