- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,691.53 / $4,365.16
| Facility | | $812.83 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $1,096.48
| Professional | | $575.44 | $741.31 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,888.44 / $9,549.93
| Facility | | $3,388.44 | $5,888.44 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $1,047.13
| Professional | | $724.44 | $851.14 | $1,047.13 |
- 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
- $501.19 / $812.83 / $1,148.15
| Professional | | $501.19 | $812.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,041.74 / $5,888.44
| Facility | | $831.76 | $2,041.74 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $758.58 / $1,202.26
| Professional | | $588.84 | $758.58 | $1,202.26 |