- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $389.05 / $524.81
| Facility | | $363.08 | $389.05 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $562.34
| Professional | | $316.23 | $380.19 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $489.78 / $489.78
| Professional | | $251.19 | $489.78 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,000.00 / $1,737.80
| Facility | | $316.23 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $3,630.78
| Professional | | $2,398.83 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $489.78 / $489.78
| Facility | | $173.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $489.78
| Professional | | $204.17 | $295.12 | $489.78 |