- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,570.40 / $6,025.60
| Facility | | $933.25 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,621.81
| Professional | | $676.08 | $977.24 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,709.64 / $12,022.64
| Facility | | $4,786.30 | $8,709.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,621.81
| Professional | | $794.33 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $660.69
| Facility | | $39.81 | $39.81 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $11,748.98
| Facility | | $1,148.15 | $5,248.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,584.89
| Professional | | $676.08 | $954.99 | $1,584.89 |