- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,445.44 / $2,398.83
| Facility | | $776.25 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $2,454.71 / $5,128.61
| Professional | | $223.87 | $2,454.71 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $4,265.80
| Facility | | $2,691.53 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $1,905.46 / $3,311.31
| Professional | | $173.78 | $1,905.46 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $467.74 / $4,466.84
| Professional | | $234.42 | $467.74 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $6,918.31
| Facility | | $1,202.26 | $4,265.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $2,344.23 / $4,677.35
| Professional | | $208.93 | $2,344.23 | $4,677.35 |