- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.80 / $1,007.00 / $4,347.20
| Facility | | $402.80 | $1,007.00 | $4,347.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.80 / $498.79 / $646.00
| Professional | | $402.80 | $498.79 | $646.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.90 / $1,675.16 / $3,482.59
| Facility | | $742.90 | $1,675.16 | $3,482.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.80 / $833.91 / $1,091.86
| Professional | | $402.80 | $833.91 | $1,091.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.00 / $380.00 / $456.00
| Professional | | $304.00 | $380.00 | $456.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.00 / $13,785.00 / $13,785.00
| Facility | | $760.00 | $13,785.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.00 / $608.00 / $684.00
| Professional | | $608.00 | $608.00 | $684.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $684.00 / $912.00
| Facility | | $418.00 | $684.00 | $912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.25 / $456.00 / $779.00
| Professional | | $294.25 | $456.00 | $779.00 |