- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,778.28
| Professional | | $812.83 | $977.24 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $4,897.79
| Facility | | $3,019.95 | $3,548.13 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $1,548.82
| Professional | | $870.96 | $1,258.93 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,148.15 / $2,041.74
| Professional | | $741.31 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,370.32 / $9,120.11
| Facility | | $2,454.71 | $5,370.32 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $954.99 / $1,778.28
| Professional | | $691.83 | $954.99 | $1,778.28 |