- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,248.07 / $9,549.93
| Facility | | $2,570.40 | $5,248.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $3,090.30
| Professional | | $891.25 | $1,230.27 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $13,803.84 / $19,952.62
| Facility | | $4,786.30 | $13,803.84 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,995.26 / $2,570.40
| Professional | | $1,000.00 | $1,995.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $2,754.23
| Professional | | $1,230.27 | $1,819.70 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,819.70
| Professional | | $1,737.80 | $1,737.80 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $2,691.53
| Professional | | $1,000.00 | $1,445.44 | $2,691.53 |