- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $669.66 / $1,471.46 / $4,185.37
| Facility | | $669.66 | $1,471.46 | $4,185.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.54 / $418.54 / $484.31
| Professional | | $418.54 | $418.54 | $484.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $983.56 / $1,157.43 / $2,977.17
| Facility | | $983.56 | $1,157.43 | $2,977.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.16 / $388.64 / $388.64
| Professional | | $239.16 | $388.64 | $388.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,079.64 / $2,185.78 / $2,622.93
| Facility | | $1,079.64 | $2,185.78 | $2,622.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.91 / $867.81 / $1,969.58
| Professional | | $597.91 | $867.81 | $1,969.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.12 / $358.75 / $597.91
| Professional | | $251.12 | $358.75 | $597.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.46 / $614.33 / $3,000.00
| Professional | | $446.46 | $614.33 | $3,000.00 |