- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $14,125.38
| Facility | | $1,380.38 | $4,897.79 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $2,089.30
| Professional | | $1,000.00 | $1,148.15 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,454.40 / $19,498.45
| Facility | | $6,456.54 | $14,454.40 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,344.23
| Professional | | $1,023.29 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,258.93
| Facility | | $1,000.00 | $1,096.48 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,344.23
| Professional | | $1,096.48 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,317.64 / $10,964.78
| Facility | | $3,890.45 | $8,317.64 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $2,089.30
| Professional | | $891.25 | $1,202.26 | $2,089.30 |