- 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
- $1,995.26 / $2,454.71 / $4,365.16
| Professional | | $1,995.26 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $3,715.35
| Professional | | $2,630.27 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $2,137.96 / $2,137.96
| Facility | | $39.81 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $3,890.45
| Facility | | $489.78 | $812.83 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $5,248.07
| Professional | | $1,698.24 | $2,884.03 | $5,248.07 |
- 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
- $1,905.46 / $2,454.71 / $4,168.69
| Professional | | $1,905.46 | $2,454.71 | $4,168.69 |