- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $4,570.88
| Facility | | $891.25 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $1,905.46
| Professional | | $912.01 | $1,174.90 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,709.64 / $12,302.69
| Facility | | $4,786.30 | $8,709.64 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,621.81
| Professional | | $1,122.02 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,148.15 / $1,698.24
| Professional | | $676.08 | $1,148.15 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $11,748.98
| Facility | | $1,148.15 | $5,248.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,698.24
| Professional | | $812.83 | $1,071.52 | $1,698.24 |