- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $16,218.10
| Facility | | $1,380.38 | $4,897.79 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $2,398.83
| Professional | | $1,000.00 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $19,952.62 / $27,542.29
| Facility | | $8,317.64 | $19,952.62 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $1,737.80
| Professional | | $891.25 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,230.27
| Facility | | $1,000.00 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,380.38 / $2,454.71
| Professional | | $1,071.52 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $10,000.00 / $18,197.01
| Facility | | $4,466.84 | $10,000.00 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,089.30
| Professional | | $891.25 | $1,230.27 | $2,089.30 |