- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,047.13 / $1,995.26
| Facility | | $501.19 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $645.65 / $1,380.38
| Professional | | $602.56 | $645.65 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Professional | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,000.00 / $1,000.00
| Facility | | $295.12 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $39.81
| Professional | | $21.38 | $25.12 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $537.03 / $1,621.81
| Facility | | $223.87 | $537.03 | $1,621.81 |