- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,818.78 / $1,818.78 / $1,818.78
| Facility | | $1,818.78 | $1,818.78 | $1,818.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,530.20 / $3,530.20 / $3,530.20
| Professional | | $3,530.20 | $3,530.20 | $3,530.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.00 / $187.00 / $373.00
| Professional | | $156.00 | $187.00 | $373.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.71 / $162.35 / $234.86
| Professional | | $127.71 | $162.35 | $234.86 |
- 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
- $146.30 / $249.83 / $401.26
| Professional | | $146.30 | $249.83 | $401.26 |