- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.47 / $3,626.53 / $5,603.72
| Facility | | $1,931.47 | $3,626.53 | $5,603.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.25 / $1,526.85 / $1,877.85
| Professional | | $1,316.25 | $1,526.85 | $1,877.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.75 / $2,193.75 / $2,193.75
| Professional | | $2,193.75 | $2,193.75 | $2,193.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.42 / $2,874.69 / $3,553.44
| Facility | | $1,551.42 | $2,874.69 | $3,553.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $1,755.00 / $2,361.02
| Facility | | $1,404.00 | $1,755.00 | $2,361.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $8,739.90
| Professional | | $737.10 | $1,053.00 | $8,739.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $631.79 / $1,755.00 / $2,632.50
| Facility | | $631.79 | $1,755.00 | $2,632.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $2,632.50
| Professional | | $737.10 | $1,053.00 | $2,632.50 |