- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,513.56 / $2,454.71
| Facility | | $891.25 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $912.01
| Professional | | $630.96 | $794.33 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,570.40
| Facility | | $1,905.46 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $912.01
| Professional | | $691.83 | $691.83 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,047.13 / $1,288.25
| Professional | | $512.86 | $1,047.13 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $6,025.60
| Facility | | $977.24 | $2,137.96 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $707.95 / $1,318.26
| Professional | | $588.84 | $707.95 | $1,318.26 |