- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $4,786.30
| Facility | | $1,148.15 | $1,148.15 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $851.14 / $2,187.76
| Professional | | $467.74 | $851.14 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $501.19 / $912.01
| Professional | | $426.58 | $501.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $707.95 / $1,122.02
| Professional | | $524.81 | $707.95 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $13,803.84 / $23,988.33
| Facility | | $4,466.84 | $13,803.84 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $724.44 / $1,148.15
| Professional | | $524.81 | $724.44 | $1,148.15 |