- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,238.72 / $3,890.45
| Facility | | $1,047.13 | $2,238.72 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $4,786.30
| Professional | | $2,187.76 | $2,398.83 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Professional | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,890.45 / $5,495.41
| Professional | | $2,454.71 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,332.54 / $21,877.62
| Facility | | $1,348.96 | $9,332.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $5,623.41
| Professional | | $2,187.76 | $2,884.03 | $5,623.41 |