- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.55 / $1,073.63 / $3,456.37
| Facility | | $949.55 | $1,073.63 | $3,456.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.55 / $987.53 / $1,076.16
| Professional | | $949.55 | $987.53 | $1,076.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.36 / $1,671.21 / $2,494.16
| Professional | | $658.36 | $1,671.21 | $2,494.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.82 / $1,983.31 / $4,521.16
| Facility | | $847.82 | $1,983.31 | $4,521.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $6,102.46
| Professional | | $1,266.07 | $1,266.07 | $6,102.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,202.96 / $6,013.83 / $6,013.83
| Facility | | $2,202.96 | $6,013.83 | $6,013.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,305.03 / $6,305.03 / $9,495.53
| Professional | | $6,305.03 | $6,305.03 | $9,495.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $759.64 / $1,266.07
| Professional | | $531.75 | $759.64 | $1,266.07 |