- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,318.26 / $1,995.26
| Facility | | $645.65 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $794.33 / $1,548.82
| Professional | | $724.44 | $794.33 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $3,467.37
| Professional | | $1,230.27 | $1,230.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,548.13 / $3,981.07
| Facility | | $3,235.94 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,621.81
| Professional | | $831.76 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,691.53 / $9,120.11
| Facility | | $794.33 | $2,691.53 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,778.28
| Professional | | $691.83 | $891.25 | $1,778.28 |