- 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
- $1,445.44 / $1,778.28 / $3,162.28
| Professional | | $1,445.44 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Professional | | $2,691.53 | $2,691.53 | $2,691.53 |
- 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
- $1,479.11 / $2,290.87 / $3,162.28
| Professional | | $1,479.11 | $2,290.87 | $3,162.28 |
- 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
- $575.44 / $1,348.96 / $4,073.80
| Facility | | $575.44 | $1,348.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $3,890.45
| Professional | | $1,380.38 | $1,862.09 | $3,890.45 |