- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $10,471.29
| Facility | | $1,949.84 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,187.76
| Professional | | $1,000.00 | $1,258.93 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $2,344.23
| Professional | | $1,047.13 | $1,513.56 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,445.44 / $4,897.79
| Facility | | $54.95 | $1,445.44 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $8,128.31
| Professional | | $1,122.02 | $1,348.96 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $5,623.41
| Facility | | $851.14 | $1,445.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $1,819.70
| Professional | | $1,122.02 | $1,288.25 | $1,819.70 |