- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $2,818.38
| Facility | | $776.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $7,943.28
| Professional | | $616.60 | $891.25 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,467.37
| Professional | | $2,570.40 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,079.46 / $10,964.78
| Facility | | $3,235.94 | $7,079.46 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $42.66 / $79.43
| Professional | | $21.38 | $42.66 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $6,025.60 / $14,125.38
| Facility | | $1,174.90 | $6,025.60 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,202.26 / $2,754.23
| Professional | | $851.14 | $1,202.26 | $2,754.23 |