- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $2,454.71
| Facility | | $1,071.52 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $1,862.09
| Professional | | $1,000.00 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $7,079.46
| Facility | | $5,248.07 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,659.59
| Professional | | $1,230.27 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,949.84 / $2,570.40
| Professional | | $602.56 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,495.41 / $11,481.54
| Facility | | $2,089.30 | $5,495.41 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $2,454.71
| Professional | | $870.96 | $1,258.93 | $2,454.71 |