- 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
- $2,344.23 / $2,630.27 / $5,128.61
| Professional | | $2,344.23 | $2,630.27 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- 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
- $2,454.71 / $3,890.45 / $5,128.61
| Professional | | $2,454.71 | $3,890.45 | $5,128.61 |
- 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
- $977.24 / $3,890.45 / $12,302.69
| Facility | | $977.24 | $3,890.45 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $6,025.60
| Professional | | $2,137.96 | $2,818.38 | $6,025.60 |