- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $6,606.93
| Facility | | $933.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $1,584.89
| Professional | | $794.33 | $977.24 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $1,445.44
| Professional | | $933.25 | $1,174.90 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $812.83
| Facility | | $39.81 | $39.81 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $7,079.46 / $14,454.40
| Facility | | $1,202.26 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $977.24 / $1,621.81
| Professional | | $776.25 | $977.24 | $1,621.81 |