- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.07 / $3,767.93 / $4,940.01
| Facility | | $719.07 | $3,767.93 | $4,940.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.07 / $2,306.48 / $3,160.17
| Professional | | $719.07 | $2,306.48 | $3,160.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,495.53 / $2,566.65 / $8,044.52
| Facility | | $2,495.53 | $2,566.65 | $8,044.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.06 / $3,500.00 / $5,341.52
| Professional | | $2,769.06 | $3,500.00 | $5,341.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,357.54 / $11,824.38
| Facility | | $2,919.60 | $3,357.54 | $11,824.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.12 / $3,149.67 / $3,499.63
| Professional | | $2,483.12 | $3,149.67 | $3,499.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $1,751.76
| Professional | | $1,226.23 | $1,226.23 | $1,751.76 |