- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,511.89 / $6,165.95
| Facility | | $1,202.26 | $2,511.89 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $1,202.26 / $1,778.28
| Professional | | $57.54 | $1,202.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $6,309.57
| Facility | | $1,202.26 | $1,905.46 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $588.84 / $1,905.46
| Professional | | $33.88 | $588.84 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $2,511.89 / $6,025.60
| Facility | | $57.54 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,137.96 / $3,548.13
| Professional | | $912.01 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $1,778.28
| Facility | | $676.08 | $1,479.11 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,737.80
| Professional | | $630.96 | $891.25 | $1,737.80 |