- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $6,606.93
| Facility | | $933.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,238.72
| Professional | | $1,122.02 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $7,079.46 / $15,848.93
| Facility | | $2,951.21 | $7,079.46 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,089.30
| Professional | | $1,445.44 | $1,698.24 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $2,344.23
| Professional | | $1,000.00 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,370.32 / $11,748.98
| Facility | | $1,148.15 | $5,370.32 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,548.82 / $2,454.71
| Professional | | $1,202.26 | $1,548.82 | $2,454.71 |