- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,511.38 / $12,302.69
| Facility | | $4,265.80 | $8,511.38 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $2,951.21
| Professional | | $1,000.00 | $1,174.90 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $3,311.31
| Professional | | $912.01 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $1,905.46
| Professional | | $1,071.52 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $16,595.87 / $31,622.78
| Facility | | $199.53 | $16,595.87 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,818.38
| Professional | | $933.25 | $1,318.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $21,379.62
| Facility | | $4,570.88 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,454.71
| Professional | | $1,000.00 | $1,380.38 | $2,454.71 |