- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,412.54 / $2,041.74
| Facility | | $398.11 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $354.81 / $436.52
| Professional | | $288.40 | $354.81 | $436.52 |
- 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 / $416.87
| Professional | | $309.03 | $309.03 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $501.19 / $575.44
| Professional | | $269.15 | $501.19 | $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
- $275.42 / $338.84 / $616.60
| Professional | | $275.42 | $338.84 | $616.60 |