- 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
- $758.58 / $1,023.29 / $1,380.38
| Professional | | $758.58 | $1,023.29 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,479.11 / $6,606.93
| Facility | | $776.25 | $1,479.11 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,412.54
| Professional | | $933.25 | $1,202.26 | $1,412.54 |
- 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
- $758.58 / $1,096.48 / $1,479.11
| Professional | | $758.58 | $1,096.48 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,148.15 / $2,754.23
| Facility | | $338.84 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,174.90 / $1,905.46
| Professional | | $794.33 | $1,174.90 | $1,905.46 |