- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.85 / $3,075.23 / $3,167.03
| Facility | | $1,463.85 | $3,075.23 | $3,167.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.85 / $3,167.03 / $3,167.03
| Professional | | $1,463.85 | $3,167.03 | $3,167.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,212.93 / $3,212.93 / $5,100.00
| Professional | | $3,212.93 | $3,212.93 | $5,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $6,067.50
| Professional | | $248.35 | $248.35 | $6,067.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $524.17 / $524.17
| Professional | | $200.00 | $524.17 | $524.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.55 / $226.76 / $1,572.39
| Professional | | $177.55 | $226.76 | $1,572.39 |