- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $651.80 / $1,758.53 / $4,195.75
| Facility | | $651.80 | $1,758.53 | $4,195.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.35 / $1,294.82 / $2,039.48
| Professional | | $319.35 | $1,294.82 | $2,039.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,029.72 / $3,029.72 / $3,635.66
| Facility | | $3,029.72 | $3,029.72 | $3,635.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $500.45 / $1,912.85
| Professional | | $340.31 | $500.45 | $1,912.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.93 / $744.88 / $2,687.65
| Professional | | $443.93 | $744.88 | $2,687.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.00 / $2,931.00 / $8,923.70
| Facility | | $1,240.00 | $2,931.00 | $8,923.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.73 / $2,043.74 / $2,968.47
| Professional | | $1,415.73 | $2,043.74 | $2,968.47 |