- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,230.27 / $2,041.74
| Facility | | $380.19 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $446.68 / $660.69
| Professional | | $302.00 | $446.68 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,949.84
| Facility | | $1,412.54 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $707.95
| Professional | | $346.74 | $467.74 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $501.19 / $794.33
| Professional | | $331.13 | $501.19 | $794.33 |
- 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
- $302.00 / $478.63 / $794.33
| Professional | | $302.00 | $478.63 | $794.33 |