- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $6,606.93
| Facility | | $933.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,691.53
| Professional | | $1,230.27 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,897.79 / $6,918.31
| Facility | | $2,570.40 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $1,949.84
| Professional | | $1,348.96 | $1,584.89 | $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 / $2,187.76
| Professional | | $933.25 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,454.71
| Professional | | $1,096.48 | $1,445.44 | $2,454.71 |