- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,454.71 / $6,606.93
| Facility | | $758.58 | $2,454.71 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $158.49 / $251.19
| Professional | | $100.00 | $158.49 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $346.74 / $1,548.82
| Facility | | $141.25 | $346.74 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $181.97 / $489.78
| Professional | | $131.83 | $181.97 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $630.96 / $1,659.59
| Facility | | $138.04 | $630.96 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $177.83 / $380.19
| Professional | | $131.83 | $177.83 | $380.19 |