- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $4,897.79
| Facility | | $1,380.38 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,819.70
| Professional | | $1,047.13 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,125.38 / $19,498.45
| Facility | | $6,456.54 | $14,125.38 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,187.76
| Professional | | $1,000.00 | $1,348.96 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $1,230.27
| Facility | | $1,047.13 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $2,344.23
| Professional | | $1,047.13 | $1,380.38 | $2,344.23 |
- 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
- $1,000.00 / $1,288.25 / $2,089.30
| Professional | | $1,000.00 | $1,288.25 | $2,089.30 |