- 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
- $1,258.93 / $1,412.54 / $3,162.28
| Professional | | $1,258.93 | $1,412.54 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,513.56
| Professional | | $1,148.15 | $1,148.15 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- 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
- $1,412.54 / $2,238.72 / $3,019.95
| Professional | | $1,412.54 | $2,238.72 | $3,019.95 |
- 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 / $4,168.69 / $11,748.98
| Facility | | $977.24 | $4,168.69 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $3,235.94
| Professional | | $1,258.93 | $1,621.81 | $3,235.94 |