- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.23 / $852.48 / $2,016.00
| Facility | | $691.23 | $852.48 | $2,016.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.19 / $1,063.16 / $1,321.20
| Facility | | $1,032.19 | $1,063.16 | $1,321.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.60 / $1,549.10 / $1,927.26
| Facility | | $1,095.60 | $1,549.10 | $1,927.26 |