- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.29 / $2,435.21 / $2,435.21
| Facility | | $526.29 | $2,435.21 | $2,435.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.82 / $296.16 / $4,025.70
| Professional | | $180.82 | $296.16 | $4,025.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.00 / $740.00 / $1,145.00
| Professional | | $503.00 | $740.00 | $1,145.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.49 / $363.07 / $620.04
| Professional | | $206.49 | $363.07 | $620.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.96 / $479.06 / $1,026.95
| Professional | | $248.96 | $479.06 | $1,026.95 |