- 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
- $2,187.76 / $2,818.38 / $3,890.45
| Professional | | $2,187.76 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $4,073.80
| Professional | | $2,691.53 | $3,235.94 | $4,073.80 |
- 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
- $1,862.09 / $3,090.30 / $4,168.69
| Professional | | $1,862.09 | $3,090.30 | $4,168.69 |
- 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
- $2,137.96 / $2,951.21 / $5,128.61
| Professional | | $2,137.96 | $2,951.21 | $5,128.61 |