- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,235.94 / $5,754.40
| Facility | | $933.25 | $3,235.94 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $4,073.80
| Professional | | $1,949.84 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $3,548.13
| Professional | | $2,630.27 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $1,905.46 / $1,905.46
| Facility | | $39.81 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $3,548.13
| Facility | | $489.78 | $812.83 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,754.23 / $5,011.87
| Professional | | $1,584.89 | $2,754.23 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,174.90 / $5,754.40
| Facility | | $371.54 | $1,174.90 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,890.45
| Professional | | $1,778.28 | $2,398.83 | $3,890.45 |