- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,630.27 / $5,888.44
| Facility | | $933.25 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,137.96
| Professional | | $1,230.27 | $1,479.11 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $11,748.98
| Facility | | $4,570.88 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $1,949.84
| Professional | | $1,348.96 | $1,659.59 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $2,454.71
| Professional | | $933.25 | $1,479.11 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $11,748.98
| Facility | | $1,148.15 | $5,248.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $2,398.83
| Professional | | $1,047.13 | $1,513.56 | $2,398.83 |