- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.14 / $1,743.95 / $3,979.87
| Facility | | $769.14 | $1,743.95 | $3,979.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.14 / $769.14 / $769.14
| Professional | | $769.14 | $769.14 | $769.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.41 / $2,559.25 / $4,316.28
| Facility | | $312.41 | $2,559.25 | $4,316.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.77 / $1,299.24 / $5,182.74
| Professional | | $784.77 | $1,299.24 | $5,182.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.97 / $1,461.90 / $6,363.60
| Facility | | $1,170.97 | $1,461.90 | $6,363.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.54 / $3,177.48 / $4,307.56
| Professional | | $2,005.54 | $3,177.48 | $4,307.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.90 / $749.61 / $3,060.46
| Professional | | $584.90 | $749.61 | $3,060.46 |