- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $7,079.46 / $14,125.38
| Facility | | $977.24 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $512.86 / $1,584.89
| Professional | | $257.04 | $512.86 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,584.89
| Professional | | $1,071.52 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $467.74 / $2,454.71
| Facility | | $295.12 | $467.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $1,737.80
| Professional | | $758.58 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $2,137.96
| Professional | | $831.76 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $562.34 / $2,454.71
| Facility | | $295.12 | $562.34 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $630.96 / $1,584.89
| Professional | | $60.26 | $630.96 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,202.26 / $1,905.46
| Professional | | $575.44 | $1,202.26 | $1,905.46 |