- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.18 / $1,642.88 / $8,462.74
| Facility | | $690.18 | $1,642.88 | $8,462.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $690.18 / $1,010.42
| Professional | | $690.18 | $690.18 | $1,010.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,016.92 / $4,722.57
| Facility | | $1,935.29 | $3,016.92 | $4,722.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.34 / $808.34 / $994.26
| Facility | | $808.34 | $808.34 | $994.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.37 / $1,384.37 / $1,384.37
| Professional | | $1,384.37 | $1,384.37 | $1,384.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.68 / $437.68 / $437.68
| Professional | | $437.68 | $437.68 | $437.68 |