- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $2,884.03
| Professional | | $1,071.52 | $1,479.11 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,585.78 / $10,471.29
| Facility | | $6,165.95 | $7,585.78 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,513.56 / $1,949.84
| Professional | | $933.25 | $1,513.56 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,778.28 / $2,818.38
| Professional | | $933.25 | $1,778.28 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $7,244.36
| Facility | | $1,479.11 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,398.83
| Professional | | $1,000.00 | $1,318.26 | $2,398.83 |