- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $5,370.32 / $7,943.28
| Facility | | $891.25 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $977.24
| Professional | | $575.44 | $891.25 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,479.11
| Professional | | $660.69 | $812.83 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $660.69 / $912.01
| Professional | | $501.19 | $660.69 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $6,309.57 / $12,022.64
| Facility | | $1,047.13 | $6,309.57 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $3,311.31
| Professional | | $891.25 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,238.72
| Professional | | $1,096.48 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,912.51 / $12,589.25
| Facility | | $6,025.60 | $8,912.51 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,348.96 / $2,238.72
| Professional | | $724.44 | $1,348.96 | $2,238.72 |