- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $4,897.79 / $7,244.36
| Facility | | $707.95 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $660.69 / $1,318.26
| Professional | | $588.84 | $660.69 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $18,197.01 / $26,302.68
| Facility | | $2,818.38 | $18,197.01 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,318.26
| Professional | | $588.84 | $831.76 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $645.65 / $724.44
| Facility | | $616.60 | $645.65 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $1,445.44
| Professional | | $602.56 | $812.83 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,025.60 / $10,715.19
| Facility | | $3,388.44 | $6,025.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,230.27
| Professional | | $575.44 | $724.44 | $1,230.27 |