- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $481.39 / $802.31 / $2,053.92
| Facility | | $481.39 | $802.31 | $2,053.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.39 / $507.06 / $850.00
| Professional | | $481.39 | $507.06 | $850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.83 / $641.85 / $2,280.00
| Professional | | $287.83 | $641.85 | $2,280.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.62 / $1,382.83 / $2,012.58
| Facility | | $186.62 | $1,382.83 | $2,012.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.19 / $426.91 / $1,093.44
| Professional | | $286.19 | $426.91 | $1,093.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.82 / $3,048.79 / $3,048.79
| Facility | | $1,116.82 | $3,048.79 | $3,048.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,209.25 / $3,209.25 / $4,813.88
| Professional | | $3,209.25 | $3,209.25 | $4,813.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.91 / $269.58 / $641.85
| Professional | | $143.91 | $269.58 | $641.85 |