- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,000.00 / $2,041.74
| Facility | | $446.68 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $371.54 / $524.81
| Professional | | $331.13 | $371.54 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $575.44 / $794.33
| Professional | | $371.54 | $575.44 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $851.14
| Facility | | $128.82 | $346.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $426.58 / $707.95
| Professional | | $331.13 | $426.58 | $707.95 |