- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $9,772.37
| Facility | | $1,148.15 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,778.28 / $3,019.95
| Professional | | $1,148.15 | $1,778.28 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,677.35 / $5,623.41
| Facility | | $4,168.69 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,168.69
| Professional | | $1,862.09 | $2,630.27 | $4,168.69 |