- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.36 / $1,514.00 / $3,168.25
| Facility | | $344.36 | $1,514.00 | $3,168.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $475.00
| Professional | | $318.75 | $318.75 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.51 / $1,099.40 / $1,195.00
| Professional | | $597.51 | $1,099.40 | $1,195.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.18 / $1,379.52 / $1,765.50
| Facility | | $458.18 | $1,379.52 | $1,765.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.81 / $1,940.81 / $1,940.81
| Professional | | $1,940.81 | $1,940.81 | $1,940.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $425.00 / $760.75
| Facility | | $318.75 | $425.00 | $760.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.87 / $1,921.87 / $1,921.87
| Professional | | $1,921.87 | $1,921.87 | $1,921.87 |