- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $4,570.88
| Facility | | $891.25 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $1,862.09
| Professional | | $870.96 | $1,122.02 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $4,365.16
| Facility | | $1,862.09 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $1,548.82
| Professional | | $1,096.48 | $1,288.25 | $1,548.82 |
- 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
- $691.83 / $1,202.26 / $1,584.89
| Professional | | $691.83 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,041.74 / $5,888.44
| Facility | | $831.76 | $2,041.74 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,737.80
| Professional | | $812.83 | $1,047.13 | $1,737.80 |