- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,513.56
| Professional | | $512.86 | $776.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $5,011.87
| Facility | | $3,090.30 | $3,630.78 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,348.96
| Professional | | $1,122.02 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,630.78 / $5,128.61
| Facility | | $954.99 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $489.78 / $1,348.96
| Professional | | $213.80 | $489.78 | $1,348.96 |