- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $147.91 / $257.04
| Professional | | $100.00 | $147.91 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,041.74
| Facility | | $1,258.93 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $204.17
| Professional | | $107.15 | $151.36 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $169.82 / $354.81
| Professional | | $104.71 | $169.82 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $562.34 / $1,318.26
| Facility | | $251.19 | $562.34 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $141.25 / $239.88
| Professional | | $91.20 | $141.25 | $239.88 |