- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,258.93
| Professional | | $660.69 | $812.83 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,585.78 / $10,715.19
| Facility | | $4,073.80 | $7,585.78 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $1,174.90
| Professional | | $831.76 | $977.24 | $1,174.90 |
- 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
- $524.81 / $933.25 / $1,230.27
| Professional | | $524.81 | $933.25 | $1,230.27 |
- 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
- $630.96 / $851.14 / $1,348.96
| Professional | | $630.96 | $851.14 | $1,348.96 |