- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $5,888.44
| Facility | | $1,949.84 | $2,818.38 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $1,905.46
| Professional | | $354.81 | $354.81 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $5,248.07
| Facility | | $2,398.83 | $3,235.94 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,570.88 / $5,128.61
| Professional | | $1,000.00 | $4,570.88 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $7,762.47
| Facility | | $1,258.93 | $1,949.84 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $4,265.80
| Professional | | $2,630.27 | $3,630.78 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $3,388.44
| Professional | | $933.25 | $1,174.90 | $3,388.44 |