- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $7,762.47
| Facility | | $1,380.38 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,380.38 / $3,235.94
| Professional | | $741.31 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $1,737.80
| Professional | | $1,412.54 | $1,584.89 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,479.11 / $2,818.38
| Professional | | $1,000.00 | $1,479.11 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,454.71
| Professional | | $2,290.87 | $2,290.87 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $3,162.28
| Professional | | $954.99 | $1,479.11 | $3,162.28 |