- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.45 / $498.70 / $2,705.16
| Facility | | $480.45 | $498.70 | $2,705.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.72 / $486.54 / $608.16
| Professional | | $425.72 | $486.54 | $608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.15 / $113.15 / $113.15
| Facility | | $113.15 | $113.15 | $113.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.17 / $113.15 / $113.15
| Professional | | $96.17 | $113.15 | $113.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $729.80 / $7,982.23 / $19,199.52
| Facility | | $729.80 | $7,982.23 | $19,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.40 / $851.44 / $11,279.72
| Professional | | $699.40 | $851.44 | $11,279.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.31 / $473.22 / $802.48
| Facility | | $395.31 | $473.22 | $802.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.78 / $2,931.38 / $2,931.38
| Professional | | $705.78 | $2,931.38 | $2,931.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.43 / $364.90 / $608.16
| Professional | | $255.43 | $364.90 | $608.16 |