- 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
- $169.82 / $512.86 / $2,884.03
| Professional | | $169.82 | $512.86 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $4,365.16
| Facility | | $2,754.23 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $426.58
| Professional | | $218.78 | $218.78 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,659.59 / $3,090.30
| Facility | | $630.96 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $186.21
| Professional | | $123.03 | $123.03 | $186.21 |