- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.75 / $811.52 / $3,922.50
| Facility | | $258.75 | $811.52 | $3,922.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.81 / $270.37 / $507.81
| Professional | | $166.81 | $270.37 | $507.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.00 / $2,971.00 / $4,707.00
| Facility | | $1,529.00 | $2,971.00 | $4,707.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.96 / $257.76 / $458.56
| Professional | | $185.96 | $257.76 | $458.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.12 / $309.41 / $329.62
| Facility | | $308.12 | $309.41 | $329.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.88 / $313.25 / $573.41
| Professional | | $206.88 | $313.25 | $573.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.86 / $1,140.00 / $2,699.00
| Facility | | $307.86 | $1,140.00 | $2,699.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.57 / $316.49 / $624.02
| Professional | | $246.57 | $316.49 | $624.02 |