- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.80 / $73.80 / $73.80
| Facility | | $73.80 | $73.80 | $73.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.16 / $81.09 / $114.98
| Professional | | $68.16 | $81.09 | $114.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,441.87 / $2,441.87 / $5,503.61
| Facility | | $2,441.87 | $2,441.87 | $5,503.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.66 / $1,438.66 / $5,979.29
| Professional | | $1,438.66 | $1,438.66 | $5,979.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.24 / $785.24 / $785.24
| Professional | | $785.24 | $785.24 | $785.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,441.87 / $2,441.87 / $5,503.61
| Facility | | $2,441.87 | $2,441.87 | $5,503.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.66 / $1,438.66 / $5,979.29
| Professional | | $1,438.66 | $1,438.66 | $5,979.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.85 / $1,438.66 / $2,379.60
| Professional | | $1,222.85 | $1,438.66 | $2,379.60 |