- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,584.89 / $2,570.40
| Facility | | $741.31 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $3,162.28
| Professional | | $676.08 | $676.08 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $5,248.07
| Facility | | $1,000.00 | $1,000.00 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $39.81
| Professional | | $21.38 | $25.12 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,168.69 / $10,964.78
| Facility | | $977.24 | $4,168.69 | $10,964.78 |