- 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
- $1,047.13 / $1,258.93 / $2,041.74
| Professional | | $1,047.13 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $1,995.26
| Professional | | $1,148.15 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,445.44 / $1,995.26
| Professional | | $794.33 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,445.44 / $4,265.80
| Facility | | $933.25 | $1,445.44 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $8,709.64
| Professional | | $1,047.13 | $1,348.96 | $8,709.64 |
- 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
- $1,000.00 / $1,230.27 / $1,819.70
| Professional | | $1,000.00 | $1,230.27 | $1,819.70 |