- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $1,000.00 / $1,949.84
| Facility | | $288.40 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $316.23 / $380.19
| Professional | | $173.78 | $316.23 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,621.81
| Facility | | $1,513.56 | $1,513.56 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $436.52 / $575.44
| Professional | | $407.38 | $436.52 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,000.00 / $2,344.23
| Facility | | $263.03 | $1,000.00 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $346.74 / $741.31
| Facility | | $288.40 | $346.74 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $407.38 / $489.78
| Facility | | $363.08 | $407.38 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $245.47
| Professional | | $104.71 | $147.91 | $245.47 |