- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,230.27 / $2,041.74
| Facility | | $416.87 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $389.05 / $501.19
| Professional | | $302.00 | $389.05 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,398.83
| Facility | | $1,737.80 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $457.09 / $616.60
| Professional | | $346.74 | $457.09 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $436.52 / $602.56
| Professional | | $263.03 | $436.52 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $4,365.16
| Facility | | $588.84 | $1,445.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $436.52 / $691.83
| Professional | | $316.23 | $436.52 | $691.83 |