- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,819.70 / $2,511.89
| Facility | | $812.83 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $630.96 / $933.25
| Professional | | $575.44 | $630.96 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $8,511.38
| Facility | | $6,165.95 | $6,165.95 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $870.96
| Professional | | $660.69 | $660.69 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $977.24 / $1,096.48
| Professional | | $512.86 | $977.24 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $1,174.90
| Professional | | $575.44 | $741.31 | $1,174.90 |