- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $1,905.46
| Professional | | $870.96 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,248.07 / $7,762.47
| Facility | | $2,691.53 | $5,248.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $1,548.82
| Professional | | $954.99 | $1,230.27 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $912.01
| Facility | | $39.81 | $39.81 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,467.37 / $8,511.38
| Facility | | $1,023.29 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $1,659.59
| Professional | | $794.33 | $977.24 | $1,659.59 |