- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,412.54 / $2,041.74
| Facility | | $371.54 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $346.74 / $467.74
| Professional | | $269.15 | $346.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,981.07
| Facility | | $2,884.03 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $407.38
| Professional | | $309.03 | $309.03 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $489.78 / $575.44
| Professional | | $245.47 | $489.78 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $7,079.46
| Facility | | $977.24 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $338.84 / $616.60
| Professional | | $269.15 | $338.84 | $616.60 |