- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,995.26 / $2,884.03
| Facility | | $891.25 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $2,951.21
| Professional | | $1,348.96 | $1,513.56 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- 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
- $1,513.56 / $2,290.87 / $2,951.21
| Professional | | $1,513.56 | $2,290.87 | $2,951.21 |
- 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 / $4,073.80 / $11,748.98
| Facility | | $977.24 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $3,388.44
| Professional | | $1,288.25 | $1,659.59 | $3,388.44 |