- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $2,290.87
| Professional | | $1,230.27 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $2,137.96
| Professional | | $1,288.25 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,737.80 / $2,398.83
| Professional | | $870.96 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,698.24 / $5,370.32
| Facility | | $1,000.00 | $1,698.24 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $9,549.93
| Professional | | $1,202.26 | $1,621.81 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,290.87
| Professional | | $1,122.02 | $1,513.56 | $2,290.87 |