- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,121.60 / $2,121.60 / $2,121.60
| Facility | | $2,121.60 | $2,121.60 | $2,121.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,360.32 / $2,360.32 / $2,360.32
| Professional | | $2,360.32 | $2,360.32 | $2,360.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.00 / $408.00 / $951.00
| Professional | | $327.00 | $408.00 | $951.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.03 / $397.13 / $718.51
| Professional | | $230.03 | $397.13 | $718.51 |
- 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
- $499.94 / $796.88 / $1,199.86
| Professional | | $499.94 | $796.88 | $1,199.86 |