- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $1,318.26
| Facility | | $977.24 | $977.24 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $50.12 / $1,995.26
| Professional | | $30.20 | $50.12 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $4.07 / $6.31
| Professional | | $3.02 | $4.07 | $6.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $1,412.54
| Professional | | $724.44 | $1,071.52 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,258.93
| Professional | | $724.44 | $1,000.00 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $60.26 / $87.10
| Professional | | $44.67 | $60.26 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $398.11
| Professional | | $275.42 | $275.42 | $398.11 |