- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,000.00 / $2,754.23
| Facility | | $316.23 | $1,000.00 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $478.63
| Professional | | $316.23 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,090.30 / $5,011.87
| Facility | | $1,949.84 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $331.13 / $537.03
| Facility | | $223.87 | $331.13 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $524.81 / $851.14
| Facility | | $154.88 | $524.81 | $851.14 |