- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,248.07 / $12,022.64
| Facility | | $1,513.56 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $3,090.30
| Professional | | $1,122.02 | $1,479.11 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,709.64 / $16,982.44
| Facility | | $3,162.28 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,090.30
| Professional | | $1,047.13 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,570.40 / $10,000.00
| Facility | | $1,148.15 | $2,570.40 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,819.70 / $4,466.84
| Professional | | $1,071.52 | $1,819.70 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,495.41 / $12,589.25
| Facility | | $1,819.70 | $5,495.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,630.27
| Professional | | $1,000.00 | $1,380.38 | $2,630.27 |