- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,398.83 / $12,022.64
| Facility | | $758.58 | $2,398.83 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $380.19 / $4,677.35
| Professional | | $354.81 | $380.19 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $758.58 / $7,079.46
| Facility | | $302.00 | $758.58 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $354.81
| Professional | | $60.26 | $60.26 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |