- 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
- $2,344.23 / $2,630.27 / $6,165.95
| Professional | | $2,344.23 | $2,630.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Professional | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $10,964.78 / $10,964.78
| Facility | | $1,000.00 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $5,011.87
| Professional | | $2,454.71 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,380.38 / $4,073.80
| Facility | | $630.96 | $1,380.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $5,370.32
| Professional | | $2,238.72 | $2,951.21 | $5,370.32 |