- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,388.44 / $9,772.37
| Facility | | $707.95 | $3,388.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,096.48 / $2,290.87
| Professional | | $263.03 | $1,096.48 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,413.10 / $15,135.61
| Facility | | $2,884.03 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,230.27 / $2,951.21
| Professional | | $281.84 | $1,230.27 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $1,698.24 / $9,549.93
| Facility | | $275.42 | $1,698.24 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $954.99 / $2,951.21
| Professional | | $295.12 | $954.99 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,495.41 / $12,302.69
| Facility | | $1,819.70 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $1,148.15 / $2,630.27
| Professional | | $269.15 | $1,148.15 | $2,630.27 |