- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,202.26 / $2,630.27
| Facility | | $407.38 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $380.19
| Professional | | $371.54 | $371.54 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $19,498.45 / $34,673.69
| Facility | | $7,413.10 | $19,498.45 | $34,673.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,174.90 / $2,630.27
| Facility | | $407.38 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $512.86
| Professional | | $371.54 | $371.54 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $21,379.62 / $26,302.68
| Facility | | $11,220.18 | $21,379.62 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | | $977.24 | $977.24 | $977.24 |