- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,388.44 / $6,025.60
| Facility | | $1,819.70 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $2,454.71
| Professional | | $1,096.48 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $1,949.84
| Professional | | $1,548.82 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $3,467.37
| Professional | | $32.36 | $33.11 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,691.53 / $3,388.44
| Professional | | $1,445.44 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,630.27 / $3,630.78
| Professional | | $1,000.00 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,630.27
| Professional | | $1,548.82 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,398.83
| Professional | | $1,122.02 | $1,445.44 | $2,398.83 |