- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,754.23 / $4,365.16
| Facility | | $933.25 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,388.44
| Professional | | $1,862.09 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,951.21
| Professional | | $2,041.74 | $2,398.83 | $2,951.21 |
- 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
- $1,445.44 / $2,187.76 / $3,388.44
| Professional | | $1,445.44 | $2,187.76 | $3,388.44 |
- 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
- $1,621.81 / $2,187.76 / $3,801.89
| Professional | | $1,621.81 | $2,187.76 | $3,801.89 |