- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $2,570.40
| Facility | | $870.96 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $2,238.72
| Professional | | $1,047.13 | $1,148.15 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- 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
- $1,174.90 / $1,819.70 / $2,398.83
| Professional | | $1,174.90 | $1,819.70 | $2,398.83 |
- 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
- $1,023.29 / $1,318.26 / $2,630.27
| Professional | | $1,023.29 | $1,318.26 | $2,630.27 |