- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $6,165.95
| Facility | | $1,698.24 | $2,238.72 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,096.48
| Professional | | $1,000.00 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $19,952.62
| Facility | | $4,897.79 | $8,128.31 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $3,388.44
| Professional | | $2,570.40 | $3,019.95 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,230.27 / $2,238.72
| Facility | | $1,096.48 | $1,230.27 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,380.38
| Professional | | $691.83 | $891.25 | $1,380.38 |