- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $5,011.87
| Facility | | $575.44 | $1,445.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $512.86 / $1,023.29
| Professional | | $338.84 | $512.86 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $4,786.30
| Facility | | $2,951.21 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $691.83 / $870.96
| Professional | | $478.63 | $691.83 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $549.54 / $1,148.15
| Professional | | $354.81 | $549.54 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,265.80
| Facility | | $831.76 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $446.68 / $812.83
| Professional | | $302.00 | $446.68 | $812.83 |