- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,691.53 / $6,025.60
| Facility | | $954.99 | $2,691.53 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,187.76
| Professional | | $1,202.26 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,709.64 / $12,302.69
| Facility | | $4,786.30 | $8,709.64 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $2,344.23
| Professional | | $1,412.54 | $1,949.84 | $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
- $1,096.48 / $1,621.81 / $2,511.89
| Professional | | $1,096.48 | $1,621.81 | $2,511.89 |
- 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
- $1,174.90 / $1,737.80 / $2,630.27
| Professional | | $1,174.90 | $1,737.80 | $2,630.27 |