- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.86 / $2,803.17 / $13,035.90
| Facility | | $1,207.86 | $2,803.17 | $13,035.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.86 / $1,709.25 / $1,937.15
| Professional | | $1,207.86 | $1,709.25 | $1,937.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,227.71 / $5,023.31 / $10,443.18
| Facility | | $2,227.71 | $5,023.31 | $10,443.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.30 / $2,985.49 / $4,152.34
| Professional | | $1,595.30 | $2,985.49 | $4,152.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,400.00 / $8,702.00
| Facility | | $1,400.00 | $1,400.00 | $8,702.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,253.45 / $1,253.45 / $1,253.45
| Facility | | $1,253.45 | $1,253.45 | $1,253.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.60 / $1,367.40 / $2,279.00
| Professional | | $911.60 | $1,367.40 | $2,279.00 |