- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,698.24 / $4,168.69
| Facility | | $660.69 | $1,698.24 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $398.11 / $1,513.56
| Professional | | $75.86 | $398.11 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,445.44 / $4,265.80
| Facility | | $630.96 | $1,445.44 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,000.00 / $2,187.76
| Facility | | $338.84 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $208.93
| Professional | | $204.17 | $204.17 | $208.93 |