- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.30 / $2,211.30 / $2,211.30
| Facility | | $2,211.30 | $2,211.30 | $2,211.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.76 / $325.76 / $325.76
| Professional | | $325.76 | $325.76 | $325.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.00 / $722.00 / $1,082.00
| Professional | | $602.00 | $722.00 | $1,082.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.66 / $540.50 / $713.06
| Professional | | $413.66 | $540.50 | $713.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.20 / $710.75 / $1,226.28
| Professional | | $464.20 | $710.75 | $1,226.28 |