- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $346.74 / $8,511.38
| Facility | | $331.13 | $346.74 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $389.05 / $1,621.81
| Professional | | $309.03 | $389.05 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $691.83 / $1,122.02
| Professional | | $537.03 | $691.83 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $457.09 / $1,000.00
| Facility | | $288.40 | $457.09 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $338.84 / $426.58
| Professional | | $223.87 | $338.84 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $346.74 / $691.83
| Professional | | $239.88 | $346.74 | $691.83 |