- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,344.23 / $4,897.79
| Facility | | $1,000.00 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $954.99 / $1,698.24
| Professional | | $831.76 | $954.99 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,054.61 / $26,302.68
| Facility | | $9,549.93 | $19,054.61 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $1,819.70
| Professional | | $831.76 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $912.01 / $1,023.29
| Facility | | $870.96 | $912.01 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,949.84
| Professional | | $870.96 | $1,148.15 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,698.24
| Professional | | $812.83 | $1,023.29 | $1,698.24 |