- 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 / $1,230.27 / $2,398.83
| Professional | | $1,000.00 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,168.69 / $5,888.44
| Facility | | $2,238.72 | $4,168.69 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,691.53
| Professional | | $1,202.26 | $1,698.24 | $2,691.53 |
- 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
- $1,122.02 / $1,548.82 / $2,398.83
| Professional | | $1,122.02 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $33,884.42
| Facility | | $8,912.51 | $8,912.51 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $10,000.00 / $10,000.00
| Professional | | $8,511.38 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,570.88 / $7,585.78
| Facility | | $2,754.23 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,348.96 / $2,290.87
| Professional | | $1,023.29 | $1,348.96 | $2,290.87 |