- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,570.40 / $6,456.54
| Facility | | $1,096.48 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $2,290.87
| Professional | | $1,000.00 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $6,606.93 / $9,772.37
| Facility | | $2,754.23 | $6,606.93 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,630.27
| Professional | | $1,202.26 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,584.89 / $2,454.71
| Professional | | $1,148.15 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $25,703.96 / $33,884.42
| Facility | | $25,703.96 | $25,703.96 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $9,772.37 / $9,772.37
| Professional | | $8,912.51 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,754.40 / $10,232.93
| Facility | | $3,235.94 | $5,754.40 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,290.87
| Professional | | $1,000.00 | $1,412.54 | $2,290.87 |