- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,230.27 / $2,041.74
| Facility | | $363.08 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $346.74 / $426.58
| Professional | | $269.15 | $346.74 | $426.58 |
- 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 / $354.81 / $467.74
| Professional | | $309.03 | $354.81 | $467.74 |
- 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
- $363.08 / $501.19 / $588.84
| Professional | | $363.08 | $501.19 | $588.84 |
- 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
- $275.42 / $338.84 / $630.96
| Professional | | $275.42 | $338.84 | $630.96 |