- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $9,120.11 / $9,120.11
| Facility | | $363.08 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $354.81 / $575.44
| Professional | | $316.23 | $354.81 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $380.19 / $467.74
| Facility | | $380.19 | $380.19 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,659.59
| Facility | | $602.56 | $602.56 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $549.54 / $3,388.44
| Professional | | $338.84 | $549.54 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $20,417.38
| Facility | | $2,454.71 | $2,454.71 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $660.69
| Professional | | $302.00 | $467.74 | $660.69 |