- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.71 / $657.14 / $952.85
| Facility | | $525.71 | $657.14 | $952.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.51 / $657.14 / $657.14
| Professional | | $634.51 | $657.14 | $657.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.25 / $558.12 / $816.90
| Professional | | $294.25 | $558.12 | $816.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.45 / $1,216.40 / $1,882.54
| Facility | | $100.45 | $1,216.40 | $1,882.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.30 / $520.38 / $1,000.00
| Professional | | $416.30 | $520.38 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.24 / $942.30 / $1,125.00
| Professional | | $40.24 | $942.30 | $1,125.00 |