- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $870.96
| Professional | | $645.65 | $758.58 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $288.40 / $602.56
| Facility | | $257.04 | $288.40 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,819.70
| Professional | | $1,000.00 | $1,000.00 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.70 / $141.25 / $5,011.87
| Facility | | $53.70 | $141.25 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $562.34 / $1,621.81
| Professional | | $489.78 | $562.34 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $2,089.30 / $2,398.83
| Professional | | $676.08 | $2,089.30 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $616.60 / $1,288.25
| Professional | | $125.89 | $616.60 | $1,288.25 |