- 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
- $1,096.48 / $1,513.56 / $2,089.30
| Professional | | $1,096.48 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,317.64 / $11,748.98
| Facility | | $4,570.88 | $8,317.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $2,344.23
| Professional | | $1,348.96 | $1,905.46 | $2,344.23 |
- 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
- $977.24 / $1,737.80 / $2,290.87
| Professional | | $977.24 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,456.54 / $12,882.50
| Facility | | $1,202.26 | $6,456.54 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $2,754.23
| Professional | | $1,023.29 | $1,584.89 | $2,754.23 |