- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $8,128.31
| Facility | | $812.83 | $1,380.38 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,778.28
| Professional | | $602.56 | $812.83 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $8,317.64 / $10,471.29
| Facility | | $3,715.35 | $8,317.64 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,318.26
| Professional | | $616.60 | $891.25 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $724.44
| Facility | | $707.95 | $707.95 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $1,380.38
| Professional | | $630.96 | $912.01 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,715.35 / $6,456.54
| Facility | | $1,548.82 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $1,318.26
| Professional | | $575.44 | $812.83 | $1,318.26 |