- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $4,570.88 / $11,220.18
| Facility | | $870.96 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,348.96
| Professional | | $575.44 | $724.44 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,413.10 / $14,791.08
| Facility | | $2,884.03 | $7,413.10 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,380.38
| Professional | | $549.54 | $724.44 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,148.15 / $4,677.35
| Facility | | $371.54 | $1,148.15 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $851.14 / $1,862.09
| Professional | | $549.54 | $851.14 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $741.31 / $1,348.96
| Professional | | $537.03 | $741.31 | $1,348.96 |