- 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
- $912.01 / $1,096.48 / $1,949.84
| Professional | | $912.01 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $1,737.80
| Professional | | $1,258.93 | $1,412.54 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $933.25 / $933.25
| Facility | | $39.81 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $1,737.80
| Facility | | $489.78 | $812.83 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $2,344.23
| Professional | | $794.33 | $1,348.96 | $2,344.23 |
- 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
- $851.14 / $1,122.02 / $1,905.46
| Professional | | $851.14 | $1,122.02 | $1,905.46 |