- 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 / $2,290.87 / $3,090.30
| Professional | | $1,862.09 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $3,467.37
| Professional | | $2,290.87 | $2,754.23 | $3,467.37 |
- 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 / $2,691.53 / $3,548.13
| Professional | | $1,445.44 | $2,691.53 | $3,548.13 |
- 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
- $1,905.46 / $3,090.30 / $4,786.30
| Professional | | $1,905.46 | $3,090.30 | $4,786.30 |