- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $630.96 / $933.25
| Facility | | $602.56 | $630.96 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $446.68 / $1,288.25
| Professional | | $213.80 | $446.68 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,122.02 / $3,311.31
| Professional | | $602.56 | $1,122.02 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $758.58 / $1,778.28
| Professional | | $269.15 | $758.58 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $5,370.32
| Facility | | $1,000.00 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $891.25 / $1,778.28
| Professional | | $302.00 | $891.25 | $1,778.28 |