- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,735.50 / $4,425.08 / $11,978.30
| Facility | | $2,735.50 | $4,425.08 | $11,978.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,826.34 / $6,935.89 / $10,987.42
| Facility | | $1,826.34 | $6,935.89 | $10,987.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.83 / $2,529.19 / $12,250.81
| Professional | | $1,738.83 | $2,529.19 | $12,250.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.73 / $5,268.67 / $8,781.12
| Facility | | $2,065.73 | $5,268.67 | $8,781.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,011.40 / $3,002.09 / $5,354.80
| Facility | | $2,011.40 | $3,002.09 | $5,354.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,260.88 / $15,010.45
| Professional | | $1,260.88 | $1,260.88 | $15,010.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,260.88 / $1,801.25
| Professional | | $1,260.88 | $1,260.88 | $1,801.25 |