- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $2,818.38
| Facility | | $870.96 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $5,248.07
| Professional | | $2,398.83 | $2,691.53 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- 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
- $2,570.40 / $3,801.89 / $5,495.41
| Professional | | $2,570.40 | $3,801.89 | $5,495.41 |
- 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
- $1,174.90 / $6,025.60 / $14,125.38
| Facility | | $1,174.90 | $6,025.60 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $5,888.44
| Professional | | $2,238.72 | $2,951.21 | $5,888.44 |