- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $10,471.29
| Facility | | $2,089.30 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,096.48
| Professional | | $660.69 | $891.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,698.24 / $5,623.41
| Facility | | $891.25 | $1,698.24 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,137.96
| Professional | | $1,000.00 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,162.28 / $4,677.35
| Facility | | $1,348.96 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,737.80
| Professional | | $1,000.00 | $1,258.93 | $1,737.80 |