- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,715.35 / $9,772.37
| Facility | | $776.25 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $407.38 / $891.25
| Professional | | $323.59 | $407.38 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $11,220.18
| Facility | | $2,089.30 | $5,248.07 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $446.68 / $870.96
| Professional | | $295.12 | $446.68 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,096.48 / $2,570.40
| Facility | | $446.68 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $537.03 / $1,202.26
| Professional | | $338.84 | $537.03 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $9,549.93
| Facility | | $1,513.56 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $812.83
| Professional | | $302.00 | $436.52 | $812.83 |