- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.13 / $1,770.32 / $7,642.43
| Facility | | $708.13 | $1,770.32 | $7,642.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.13 / $1,042.15 / $1,135.68
| Professional | | $708.13 | $1,042.15 | $1,135.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.03 / $1,973.55 / $4,207.38
| Facility | | $1,306.03 | $1,973.55 | $4,207.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.89 / $1,750.28 / $2,434.36
| Professional | | $1,402.89 | $1,750.28 | $2,434.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.64 / $315.64 / $8,702.00
| Facility | | $315.64 | $315.64 | $8,702.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.48 / $1,202.48 / $1,603.31
| Facility | | $1,202.48 | $1,202.48 | $1,603.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $801.65 / $1,362.81
| Professional | | $517.29 | $801.65 | $1,362.81 |