- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,951.21 / $6,606.93
| Facility | | $1,000.00 | $2,951.21 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,981.07 / $6,606.93
| Professional | | $3,467.37 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $6,165.95
| Professional | | $4,073.80 | $5,011.87 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $3,548.13 / $7,244.36
| Facility | | $489.78 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,677.35 / $28,183.83
| Professional | | $3,630.78 | $4,677.35 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $6,025.60
| Professional | | $3,388.44 | $4,265.80 | $6,025.60 |