- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $1,548.82
| Professional | | $933.25 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $8,128.31
| Facility | | $2,951.21 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $1,737.80
| Professional | | $1,148.15 | $1,380.38 | $1,737.80 |
- 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
- $954.99 / $1,348.96 / $1,819.70
| Professional | | $954.99 | $1,348.96 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $6,165.95
| Facility | | $389.05 | $1,230.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,137.96
| Professional | | $933.25 | $1,348.96 | $2,137.96 |