- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $2,630.27 / $6,760.83
| Facility | | $524.81 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $812.83
| Professional | | $302.00 | $467.74 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $707.95
| Professional | | $316.23 | $446.68 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $602.56 / $3,801.89
| Facility | | $338.84 | $602.56 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $3,801.89
| Professional | | $416.87 | $562.34 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,949.84 / $3,801.89
| Facility | | $575.44 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $407.38 / $616.60
| Professional | | $269.15 | $407.38 | $616.60 |