- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,715.35 / $9,549.93
| Facility | | $831.76 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $549.54 / $1,230.27
| Professional | | $446.68 | $549.54 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,715.35 / $8,709.64
| Facility | | $1,513.56 | $3,715.35 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $616.60 / $1,230.27
| Professional | | $416.87 | $616.60 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $1,584.89 / $3,890.45
| Facility | | $208.93 | $1,584.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $724.44 / $1,659.59
| Professional | | $478.63 | $724.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $1,071.52 / $3,467.37
| Facility | | $204.17 | $1,071.52 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $1,122.02
| Professional | | $407.38 | $575.44 | $1,122.02 |