- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,174.90 / $2,630.27
| Facility | | $724.44 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,819.70
| Professional | | $691.83 | $891.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $12,022.64
| Facility | | $2,290.87 | $5,623.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $2,041.74
| Professional | | $776.25 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,412.54 / $6,309.57
| Facility | | $398.11 | $1,412.54 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,230.27 / $2,454.71
| Professional | | $794.33 | $1,230.27 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $6,309.57
| Facility | | $1,000.00 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,023.29 / $1,862.09
| Professional | | $691.83 | $1,023.29 | $1,862.09 |