- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $442.00 / $3,481.56 / $3,481.56
| Facility | | $442.00 | $3,481.56 | $3,481.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.16 / $2,789.40 / $2,892.67
| Professional | | $1,754.16 | $2,789.40 | $2,892.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,815.72 / $2,815.72 / $2,815.72
| Facility | | $2,815.72 | $2,815.72 | $2,815.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.01 / $293.88 / $450.58
| Professional | | $189.01 | $293.88 | $450.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.10 / $1,412.33 / $3,693.21
| Professional | | $257.10 | $1,412.33 | $3,693.21 |