- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,148.15 / $3,090.30
| Facility | | $537.03 | $1,148.15 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $489.78 / $870.96
| Professional | | $398.11 | $489.78 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $2,754.23
| Facility | | $537.03 | $758.58 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $331.13 / $2,137.96
| Professional | | $239.88 | $331.13 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,148.15 / $2,691.53
| Facility | | $389.05 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $724.44 / $1,445.44
| Professional | | $302.00 | $724.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $602.56 / $724.44
| Facility | | $107.15 | $602.56 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $251.19 / $602.56
| Professional | | $39.81 | $251.19 | $602.56 |