- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $1,737.80
| Professional | | $851.14 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $4,365.16
| Facility | | $2,691.53 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $1,659.59
| Professional | | $1,000.00 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,148.15 / $1,819.70
| Professional | | $457.09 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,467.37 / $5,128.61
| Facility | | $1,122.02 | $3,467.37 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,513.56
| Professional | | $707.95 | $1,000.00 | $1,513.56 |