- 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
- $1,202.26 / $1,513.56 / $2,238.72
| Professional | | $1,202.26 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $7,762.47
| Facility | | $3,019.95 | $5,623.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,137.96
| Professional | | $1,513.56 | $1,778.28 | $2,137.96 |
- 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
- $954.99 / $1,659.59 / $2,238.72
| Professional | | $954.99 | $1,659.59 | $2,238.72 |
- 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
- $1,122.02 / $1,479.11 / $2,344.23
| Professional | | $1,122.02 | $1,479.11 | $2,344.23 |