- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,570.88 / $11,220.18
| Facility | | $1,230.27 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $2,754.23
| Professional | | $1,023.29 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,495.41 / $12,022.64
| Facility | | $2,344.23 | $5,495.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,548.82 / $2,818.38
| Professional | | $1,023.29 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,388.44 / $10,000.00
| Facility | | $1,548.82 | $3,388.44 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,778.28 / $3,715.35
| Professional | | $1,096.48 | $1,778.28 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $10,000.00
| Facility | | $1,584.89 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,630.27
| Professional | | $1,023.29 | $1,445.44 | $2,630.27 |