- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,041.74
| Facility | | $870.96 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $1,047.13
| Professional | | $588.84 | $691.83 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,122.02 / $1,445.44
| Professional | | $707.95 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $851.14
| Facility | | $128.82 | $346.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,318.26
| Professional | | $616.60 | $812.83 | $1,318.26 |