- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $2,238.72
| Professional | | $1,071.52 | $1,288.25 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $2,041.74
| Professional | | $1,445.44 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $1,096.48 / $1,096.48
| Facility | | $39.81 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $2,041.74
| Facility | | $489.78 | $812.83 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $2,754.23
| Professional | | $933.25 | $1,548.82 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,174.90 / $5,754.40
| Facility | | $371.54 | $1,174.90 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,238.72
| Professional | | $1,000.00 | $1,288.25 | $2,238.72 |