- 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
- $1,148.15 / $1,258.93 / $2,511.89
| Professional | | $1,148.15 | $1,258.93 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- 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
- $1,288.25 / $1,995.26 / $2,630.27
| Professional | | $1,288.25 | $1,995.26 | $2,630.27 |
- 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
- $1,122.02 / $1,445.44 / $2,884.03
| Professional | | $1,122.02 | $1,445.44 | $2,884.03 |