- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,467.37 / $4,365.16
| Facility | | $933.25 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $4,786.30
| Professional | | $2,238.72 | $2,691.53 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $4,265.80
| Professional | | $3,162.28 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $2,290.87 / $2,290.87
| Facility | | $39.81 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $4,265.80
| Facility | | $489.78 | $812.83 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $5,754.40
| Professional | | $1,949.84 | $3,235.94 | $5,754.40 |
- 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
- $2,089.30 / $2,754.23 / $4,677.35
| Professional | | $2,089.30 | $2,754.23 | $4,677.35 |