- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,513.56 / $3,715.35
| Facility | | $741.31 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $724.44 / $1,318.26
| Professional | | $309.03 | $724.44 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $3,890.45
| Facility | | $758.58 | $1,148.15 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $371.54 / $1,318.26
| Professional | | $33.11 | $371.54 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,659.59 / $3,715.35
| Facility | | $501.19 | $1,659.59 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,096.48 / $2,187.76
| Professional | | $426.58 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $891.25 / $1,071.52
| Facility | | $537.03 | $891.25 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $1,071.52
| Professional | | $380.19 | $537.03 | $1,071.52 |