- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $812.83 / $1,819.70
| Professional | | $371.54 | $812.83 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $6,456.54
| Facility | | $3,981.07 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,023.29 / $1,905.46
| Professional | | $416.87 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $776.25 / $3,548.13
| Professional | | $363.08 | $776.25 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,884.03 / $4,168.69
| Facility | | $758.58 | $2,884.03 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $741.31 / $3,388.44
| Professional | | $309.03 | $741.31 | $3,388.44 |