- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $5,495.41
| Facility | | $870.96 | $1,445.44 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,445.44 / $4,265.80
| Professional | | $354.81 | $1,445.44 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,888.44 / $7,943.28
| Facility | | $4,897.79 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,122.02 / $1,778.28
| Professional | | $263.03 | $1,122.02 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $602.56 / $2,454.71
| Professional | | $316.23 | $602.56 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,548.13 / $5,011.87
| Facility | | $1,096.48 | $3,548.13 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $1,148.15 / $2,344.23
| Professional | | $295.12 | $1,148.15 | $2,344.23 |