- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $1,513.56
| Professional | | $1,000.00 | $1,230.27 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $2,041.74
| Facility | | $151.36 | $151.36 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $2,187.76
| Professional | | $162.18 | $162.18 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,513.56 / $3,019.95
| Facility | | $302.00 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $912.01 / $1,071.52
| Professional | | $162.18 | $912.01 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $977.24 / $1,548.82
| Facility | | $128.82 | $977.24 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,737.80
| Professional | | $831.76 | $1,023.29 | $1,737.80 |