- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $10,964.78 / $16,595.87
| Facility | | $3,162.28 | $10,964.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $5,623.41
| Professional | | $1,000.00 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Professional | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $8,128.31
| Facility | | $933.25 | $933.25 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,630.78
| Professional | | $2,187.76 | $2,570.40 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,365.16 / $6,025.60
| Professional | | $2,238.72 | $4,365.16 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,621.81 / $8,128.31
| Facility | | $933.25 | $1,621.81 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,479.11 / $3,630.78
| Professional | | $60.26 | $1,479.11 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,884.03 / $4,365.16
| Professional | | $1,348.96 | $2,884.03 | $4,365.16 |