- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $8,511.38
| Facility | | $933.25 | $1,071.52 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,584.89
| Professional | | $758.58 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,511.89
| Professional | | $1,698.24 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,819.70 / $3,019.95
| Professional | | $851.14 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,454.71
| Facility | | $933.25 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,548.82 / $7,413.10
| Professional | | $812.83 | $1,548.82 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $5,128.61
| Facility | | $2,570.40 | $3,311.31 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,584.89 / $2,187.76
| Professional | | $851.14 | $1,584.89 | $2,187.76 |