- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,951.21 / $4,365.16
| Facility | | $933.25 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $3,630.78
| Professional | | $1,995.26 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,709.64 / $12,022.64
| Facility | | $5,128.61 | $8,709.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,162.28
| Professional | | $2,187.76 | $2,570.40 | $3,162.28 |
- 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
- $1,513.56 / $2,290.87 / $3,630.78
| Professional | | $1,513.56 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,230.27 / $6,165.95
| Facility | | $389.05 | $1,230.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $3,981.07
| Professional | | $1,698.24 | $2,290.87 | $3,981.07 |