- 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
- $1,096.48 / $1,380.38 / $2,238.72
| Professional | | $1,096.48 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,548.82 / $2,137.96
| Professional | | $851.14 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $4,570.88
| Facility | | $1,000.00 | $1,548.82 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $9,120.11
| Professional | | $1,122.02 | $1,445.44 | $9,120.11 |
- 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
- $1,023.29 / $1,318.26 / $1,949.84
| Professional | | $1,023.29 | $1,318.26 | $1,949.84 |