- 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
- $2,511.89 / $3,090.30 / $4,365.16
| Professional | | $2,511.89 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,079.46 / $9,772.37
| Facility | | $4,073.80 | $7,079.46 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,168.69 / $5,128.61
| Professional | | $3,388.44 | $4,168.69 | $5,128.61 |
- 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
- $2,290.87 / $3,630.78 / $5,011.87
| Professional | | $2,290.87 | $3,630.78 | $5,011.87 |
- 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
- $2,398.83 / $3,388.44 / $5,623.41
| Professional | | $2,398.83 | $3,388.44 | $5,623.41 |