- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.00 / $801.96 / $1,963.35
| Facility | | $750.00 | $801.96 | $1,963.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.41 / $230.68 / $4,390.95
| Professional | | $138.41 | $230.68 | $4,390.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.72 / $802.55 / $63,311.31
| Facility | | $253.72 | $802.55 | $63,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.26 / $253.72 / $849.83
| Professional | | $210.26 | $253.72 | $849.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.41 / $308.98 / $1,310.03
| Professional | | $138.41 | $308.98 | $1,310.03 |