- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,964.78 / $16,595.87
| Facility | | $3,890.45 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $1,000.00
| Professional | | $537.03 | $812.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,445.44
| Facility | | $1,000.00 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,000.00
| Professional | | $741.31 | $870.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $3,630.78
| Professional | | $1,778.28 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $1,445.44
| Facility | | $1,000.00 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,862.09 / $6,025.60
| Professional | | $1,071.52 | $1,862.09 | $6,025.60 |