- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $1,122.02
| Facility | | $691.83 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,235.94
| Professional | | $1,737.80 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,137.96
| Facility | | $1,548.82 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,344.23 / $5,495.41
| Facility | | $630.96 | $2,344.23 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $660.69 / $831.76
| Professional | | $380.19 | $660.69 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,011.87 / $9,332.54
| Facility | | $3,890.45 | $5,011.87 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,548.82 / $3,630.78
| Professional | | $512.86 | $1,548.82 | $3,630.78 |