- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,047.13 / $1,862.09
| Facility | | $630.96 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $616.60 / $741.31
| Professional | | $512.86 | $616.60 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $398.11 / $588.84
| Professional | | $309.03 | $398.11 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $11,748.98 / $46,773.51
| Facility | | $776.25 | $11,748.98 | $46,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $14,454.40
| Professional | | $831.76 | $1,047.13 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,230.27 / $1,230.27
| Facility | | $501.19 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,715.35 / $3,715.35
| Professional | | $1,096.48 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $467.74 / $776.25
| Professional | | $323.59 | $467.74 | $776.25 |