- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,230.27 / $2,041.74
| Facility | | $398.11 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $562.34
| Professional | | $302.00 | $416.87 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Facility | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $467.74 / $630.96
| Professional | | $354.81 | $467.74 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $501.19 / $707.95
| Professional | | $331.13 | $501.19 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,890.45 / $7,762.47
| Facility | | $1,548.82 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $707.95
| Professional | | $302.00 | $436.52 | $707.95 |