- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $912.01 / $1,288.25
| Professional | | $724.44 | $912.01 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,265.80 / $8,912.51
| Facility | | $2,187.76 | $4,265.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,380.38
| Professional | | $912.01 | $1,071.52 | $1,380.38 |
- 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
- $602.56 / $1,071.52 / $1,380.38
| Professional | | $602.56 | $1,071.52 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,162.28 / $8,317.64
| Facility | | $1,023.29 | $3,162.28 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $954.99 / $1,513.56
| Professional | | $707.95 | $954.99 | $1,513.56 |