- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $2,951.21
| Facility | | $776.25 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,162.28 / $6,309.57
| Professional | | $2,884.03 | $3,162.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,011.87 / $6,309.57
| Professional | | $3,235.94 | $5,011.87 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,332.54 / $21,877.62
| Facility | | $1,348.96 | $9,332.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,630.78 / $7,413.10
| Professional | | $2,818.38 | $3,630.78 | $7,413.10 |