- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,691.53 / $6,606.93
| Facility | | $891.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $354.81 / $562.34
| Professional | | $302.00 | $354.81 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,606.93 / $12,882.50
| Facility | | $3,630.78 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $398.11 / $489.78
| Professional | | $338.84 | $398.11 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $407.38 / $562.34
| Professional | | $281.84 | $407.38 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $10,715.19
| Facility | | $1,023.29 | $3,548.13 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $363.08 / $616.60
| Professional | | $275.42 | $363.08 | $616.60 |