- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,995.26 / $3,890.45
| Facility | | $1,047.13 | $1,995.26 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $3,388.44
| Professional | | $1,548.82 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |
- 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
- $1,737.80 / $2,691.53 / $3,388.44
| Professional | | $1,737.80 | $2,691.53 | $3,388.44 |
- 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 / $19,498.45
| Facility | | $1,348.96 | $9,332.54 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $3,981.07
| Professional | | $1,445.44 | $1,905.46 | $3,981.07 |