- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,630.27 / $5,888.44
| Facility | | $933.25 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $1,737.80
| Professional | | $954.99 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,370.32 / $7,762.47
| Facility | | $2,951.21 | $5,370.32 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $1,862.09
| Professional | | $1,202.26 | $1,412.54 | $1,862.09 |
- 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
- $794.33 / $1,380.38 / $1,819.70
| Professional | | $794.33 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,949.84
| Professional | | $933.25 | $1,258.93 | $1,949.84 |