- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.43 / $2,386.44 / $3,128.80
| Facility | | $455.43 | $2,386.44 | $3,128.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $455.43
| Professional | | $455.43 | $455.43 | $455.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,353.34 / $2,420.41 / $7,586.16
| Facility | | $2,353.34 | $2,420.41 | $7,586.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,303.90 / $3,303.90 / $3,303.90
| Professional | | $3,303.90 | $3,303.90 | $3,303.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,753.25 / $3,166.24 / $3,303.90
| Facility | | $2,753.25 | $3,166.24 | $3,303.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,503.94 / $2,851.01 / $3,818.75
| Professional | | $2,503.94 | $2,851.01 | $3,818.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,156.36 / $1,651.95
| Professional | | $1,156.36 | $1,156.36 | $1,651.95 |