- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,888.44 / $9,549.93
| Facility | | $1,905.46 | $5,888.44 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,905.46
| Professional | | $1,862.09 | $1,862.09 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,265.80 / $8,709.64
| Facility | | $1,737.80 | $4,265.80 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $1,905.46
| Professional | | $1,148.15 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,819.70 / $1,949.84
| Professional | | $457.09 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,235.94 / $3,235.94
| Professional | | $1,000.00 | $3,235.94 | $3,235.94 |