- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,819.70 / $2,818.38
| Facility | | $776.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $5,011.87
| Professional | | $1,862.09 | $2,290.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- 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
- $1,905.46 / $2,754.23 / $3,981.07
| Professional | | $1,905.46 | $2,754.23 | $3,981.07 |
- 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
- $724.44 / $1,445.44 / $4,073.80
| Facility | | $724.44 | $1,445.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $5,128.61
| Professional | | $1,737.80 | $2,344.23 | $5,128.61 |