- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.15 / $1,496.71 / $4,257.18
| Facility | | $681.15 | $1,496.71 | $4,257.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.72 / $425.72 / $492.62
| Professional | | $425.72 | $425.72 | $492.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.44 / $1,111.73 / $2,371.86
| Facility | | $1,000.44 | $1,111.73 | $2,371.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.15 / $395.31 / $395.31
| Professional | | $113.15 | $395.31 | $395.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,098.17 / $2,222.89 / $2,667.95
| Facility | | $1,098.17 | $2,222.89 | $2,667.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.16 / $825.41 / $1,877.12
| Professional | | $608.16 | $825.41 | $1,877.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.43 / $364.90 / $364.90
| Professional | | $255.43 | $364.90 | $364.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |