- 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
- $1,584.89 / $1,905.46 / $2,570.40
| Professional | | $1,584.89 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $2,951.21
| Professional | | $1,905.46 | $2,344.23 | $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
- $1,412.54 / $2,187.76 / $2,951.21
| Professional | | $1,412.54 | $2,187.76 | $2,951.21 |
- 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
- $1,479.11 / $2,238.72 / $3,548.13
| Professional | | $1,479.11 | $2,238.72 | $3,548.13 |