- 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
- $1,288.25 / $1,621.81 / $3,090.30
| Professional | | $1,288.25 | $1,621.81 | $3,090.30 |
- 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 / $30,902.95
| Facility | | $1,000.00 | $1,000.00 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $3,311.31
| Professional | | $1,380.38 | $2,238.72 | $3,311.31 |
- 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
- $1,348.96 / $1,819.70 / $3,715.35
| Professional | | $1,348.96 | $1,819.70 | $3,715.35 |