- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,995.26 / $2,884.03
| Facility | | $891.25 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $1,995.26
| Professional | | $891.25 | $1,023.29 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $5,248.07
| Professional | | $1,621.81 | $1,621.81 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $6,606.93
| Facility | | $3,235.94 | $3,630.78 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $1,905.46
| Professional | | $954.99 | $1,479.11 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,073.80 / $12,302.69
| Facility | | $977.24 | $4,073.80 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $2,137.96
| Professional | | $831.76 | $1,071.52 | $2,137.96 |