- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.73 / $1,469.36 / $3,527.82
| Facility | | $706.73 | $1,469.36 | $3,527.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $1,067.16
| Professional | | $507.78 | $507.78 | $1,067.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,980.71 / $1,980.71
| Professional | | $150.00 | $1,980.71 | $1,980.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.63 / $781.98 / $2,153.03
| Facility | | $362.63 | $781.98 | $2,153.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.85 / $11,716.61 / $17,124.28
| Facility | | $2,084.85 | $11,716.61 | $17,124.28 |