- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,370.32 / $12,882.50
| Facility | | $1,380.38 | $5,370.32 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $3,019.95
| Professional | | $1,000.00 | $1,174.90 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $9,549.93 / $17,782.79
| Facility | | $3,235.94 | $9,549.93 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $2,344.23
| Professional | | $933.25 | $1,258.93 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,754.23 / $6,918.31
| Facility | | $831.76 | $2,754.23 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $3,019.95
| Professional | | $870.96 | $1,445.44 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,606.93 / $15,848.93
| Facility | | $1,778.28 | $6,606.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,238.72
| Professional | | $891.25 | $1,258.93 | $2,238.72 |