- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.93 / $3,695.07 / $7,879.32
| Facility | | $1,485.93 | $3,695.07 | $7,879.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.90 / $1,545.07 / $2,290.21
| Professional | | $1,340.90 | $1,545.07 | $2,290.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,726.18 / $8,173.49 / $13,263.73
| Facility | | $3,726.18 | $8,173.49 | $13,263.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.38 / $1,743.77 / $2,908.72
| Professional | | $1,357.38 | $1,743.77 | $2,908.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $1,661.76
| Facility | | $680.00 | $870.49 | $1,661.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.18 / $2,058.09 / $3,442.07
| Professional | | $1,317.18 | $2,058.09 | $3,442.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $718.00 / $2,575.00 / $7,326.50
| Facility | | $718.00 | $2,575.00 | $7,326.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.50 / $1,819.34 / $3,253.72
| Professional | | $1,302.50 | $1,819.34 | $3,253.72 |