- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,023.29 / $1,778.28
| Facility | | $616.60 | $1,023.29 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $602.56 / $724.44
| Professional | | $501.19 | $602.56 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $1,202.26
| Professional | | $338.84 | $338.84 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $11,220.18 / $41,686.94
| Facility | | $891.25 | $11,220.18 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $13,803.84
| Professional | | $831.76 | $1,047.13 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,202.26 / $1,202.26
| Facility | | $489.78 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $741.31
| Professional | | $316.23 | $446.68 | $741.31 |