- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,294.00 / $6,986.00 / $12,831.00
| Facility | | $4,294.00 | $6,986.00 | $12,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.22 / $2,331.83 / $4,404.71
| Professional | | $1,648.22 | $2,331.83 | $4,404.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.16 / $1,868.16 / $1,868.16
| Professional | | $1,868.16 | $1,868.16 | $1,868.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.48 / $1,197.04 / $2,597.84
| Professional | | $1,017.48 | $1,197.04 | $2,597.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,682.00 / $10,536.00 / $23,291.00
| Facility | | $5,682.00 | $10,536.00 | $23,291.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.97 / $1,662.42 / $3,694.42
| Professional | | $1,057.97 | $1,662.42 | $3,694.42 |