- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $887.23 / $1,949.53 / $5,545.19
| Facility | | $887.23 | $1,949.53 | $5,545.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.52 / $641.66 / $641.66
| Professional | | $554.52 | $641.66 | $641.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,303.11 / $1,448.09 / $3,089.46
| Facility | | $1,303.11 | $1,448.09 | $3,089.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.36 / $514.91 / $608.38
| Professional | | $201.36 | $514.91 | $608.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,807.33 / $2,487.02 / $2,895.62
| Facility | | $1,807.33 | $2,487.02 | $2,895.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.25 / $910.25 / $1,137.82
| Professional | | $910.25 | $910.25 | $1,137.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.13 / $1,318.96 / $2,609.48
| Professional | | $1,075.13 | $1,318.96 | $2,609.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.71 / $475.30 / $475.30
| Professional | | $332.71 | $475.30 | $475.30 |