- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,819.70 / $3,467.37
| Facility | | $741.31 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $741.31 / $812.83
| Professional | | $537.03 | $741.31 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $7,413.10
| Facility | | $5,370.32 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $812.83
| Professional | | $616.60 | $616.60 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $954.99 / $1,318.26
| Professional | | $501.19 | $954.99 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $645.65 / $1,202.26
| Professional | | $524.81 | $645.65 | $1,202.26 |