- 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 / $2,951.21 / $4,677.35
| Professional | | $2,511.89 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,332.54 / $13,182.57
| Facility | | $5,495.41 | $9,332.54 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $4,677.35
| Professional | | $3,090.30 | $3,801.89 | $4,677.35 |
- 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
- $2,089.30 / $3,311.31 / $4,897.79
| Professional | | $2,089.30 | $3,311.31 | $4,897.79 |
- 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
- $2,290.87 / $3,235.94 / $6,025.60
| Professional | | $2,290.87 | $3,235.94 | $6,025.60 |