- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,344.23 / $4,897.79
| Facility | | $891.25 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $933.25 / $1,412.54
| Professional | | $812.83 | $933.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $17,378.01 / $25,703.96
| Facility | | $8,317.64 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,862.09
| Professional | | $831.76 | $1,202.26 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $851.14 / $912.01
| Facility | | $758.58 | $851.14 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $2,041.74
| Facility | | $831.76 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $3,019.95
| Professional | | $812.83 | $1,148.15 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,071.52 / $1,698.24
| Professional | | $776.25 | $1,071.52 | $1,698.24 |