- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $9,332.54 / $9,332.54
| Facility | | $363.08 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $812.83 / $1,819.70
| Professional | | $363.08 | $812.83 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $616.60 / $616.60
| Facility | | $34.67 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $891.25 / $6,606.93
| Professional | | $371.54 | $891.25 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $9,332.54
| Facility | | $2,454.71 | $2,454.71 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $691.83 / $4,168.69
| Professional | | $316.23 | $691.83 | $4,168.69 |