- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,235.94 / $4,365.16
| Facility | | $933.25 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $4,365.16
| Professional | | $2,691.53 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $5,011.87
| Professional | | $3,235.94 | $3,981.07 | $5,011.87 |
- 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
- $2,344.23 / $3,630.78 / $4,897.79
| Professional | | $2,344.23 | $3,630.78 | $4,897.79 |
- 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
- $2,511.89 / $3,715.35 / $5,888.44
| Professional | | $2,511.89 | $3,715.35 | $5,888.44 |