- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,818.38 / $8,709.64
| Facility | | $588.84 | $2,818.38 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $501.19 / $1,047.13
| Professional | | $416.87 | $501.19 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,630.78 / $8,709.64
| Facility | | $1,445.44 | $3,630.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $1,096.48
| Professional | | $389.05 | $562.34 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $776.25 / $3,630.78
| Facility | | $331.13 | $776.25 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $660.69 / $1,412.54
| Professional | | $446.68 | $660.69 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $1,071.52 / $3,467.37
| Facility | | $204.17 | $1,071.52 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $1,000.00
| Professional | | $380.19 | $537.03 | $1,000.00 |