- 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
- $1,023.29 / $1,202.26 / $2,187.76
| Professional | | $1,023.29 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,949.84
| Professional | | $1,412.54 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $1,047.13 / $1,047.13
| Facility | | $39.81 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $1,905.46
| Facility | | $489.78 | $812.83 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $2,754.23
| Professional | | $891.25 | $1,548.82 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,174.90 / $5,754.40
| Facility | | $371.54 | $1,174.90 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,344.23
| Professional | | $933.25 | $1,318.26 | $2,344.23 |