- 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
- $1,348.96 / $1,659.59 / $2,951.21
| Professional | | $1,348.96 | $1,659.59 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,000.00
| Facility | | $588.84 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $3,019.95
| Professional | | $1,380.38 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $5,754.40 / $10,471.29
| Facility | | $1,174.90 | $5,754.40 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $3,801.89
| Professional | | $1,288.25 | $1,698.24 | $3,801.89 |