- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,778.28
| Professional | | $1,000.00 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,606.93 / $11,481.54
| Facility | | $3,981.07 | $6,606.93 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $1,621.81
| Professional | | $1,071.52 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,174.90 / $1,862.09
| Professional | | $676.08 | $1,174.90 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,754.23 / $8,709.64
| Facility | | $831.76 | $2,754.23 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $2,041.74
| Professional | | $812.83 | $1,096.48 | $2,041.74 |