- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $1,445.44
| Facility | | $870.96 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $44.67 / $1,445.44
| Professional | | $32.36 | $44.67 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $831.76 / $1,174.90
| Professional | | $575.44 | $831.76 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $204.17 / $616.60
| Facility | | $186.21 | $204.17 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $1,513.56
| Professional | | $630.96 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $70.79
| Professional | | $39.81 | $50.12 | $70.79 |