- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,388.44 / $9,772.37
| Facility | | $891.25 | $3,388.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $549.54 / $724.44
| Professional | | $223.87 | $549.54 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $21,379.62
| Facility | | $4,570.88 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $512.86 / $1,071.52
| Professional | | $302.00 | $512.86 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,202.26 / $1,202.26
| Facility | | $630.96 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $3,548.13 / $3,548.13
| Professional | | $851.14 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $10,471.29
| Facility | | $794.33 | $3,311.31 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,380.38
| Professional | | $478.63 | $741.31 | $1,380.38 |