- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.01 / $2,015.01 / $2,015.01
| Facility | | $2,015.01 | $2,015.01 | $2,015.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.00 / $487.58 / $1,500.00
| Professional | | $325.00 | $487.58 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.82 / $861.71 / $1,074.95
| Facility | | $122.82 | $861.71 | $1,074.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.77 / $1,215.79 / $2,137.28
| Facility | | $1,083.77 | $1,215.79 | $2,137.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.55 / $182.55 / $228.18
| Professional | | $182.55 | $182.55 | $228.18 |