- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,137.96 / $7,762.47
| Facility | | $602.56 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $602.56 / $741.31
| Professional | | $316.23 | $602.56 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $562.34 / $741.31
| Professional | | $501.19 | $562.34 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $645.65 / $1,230.27
| Professional | | $407.38 | $645.65 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,071.52
| Professional | | $1,000.00 | $1,000.00 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $676.08 / $1,380.38
| Professional | | $457.09 | $676.08 | $1,380.38 |