- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,513.56 / $3,890.45
| Facility | | $676.08 | $1,513.56 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $2,089.30
| Professional | | $1,071.52 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $1,548.82
| Facility | | $1,288.25 | $1,513.56 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $1,995.26
| Professional | | $1,318.26 | $1,621.81 | $1,995.26 |
- 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
- $870.96 / $1,479.11 / $1,995.26
| Professional | | $870.96 | $1,479.11 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $933.25 / $2,187.76
| Facility | | $323.59 | $933.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,187.76
| Professional | | $977.24 | $1,318.26 | $2,187.76 |