- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,691.53 / $4,365.16
| Facility | | $891.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $776.25 / $1,122.02
| Professional | | $616.60 | $776.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $6,918.31
| Facility | | $1,905.46 | $3,467.37 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,071.52
| Professional | | $758.58 | $891.25 | $1,071.52 |
- 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
- $478.63 / $851.14 / $1,122.02
| Professional | | $478.63 | $851.14 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,454.71 / $5,888.44
| Facility | | $831.76 | $2,454.71 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $776.25 / $1,230.27
| Professional | | $575.44 | $776.25 | $1,230.27 |