- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,995.26 / $3,801.89
| Facility | | $1,047.13 | $1,995.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,454.71
| Professional | | $1,122.02 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,000.00
| Facility | | $588.84 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,454.71
| Professional | | $1,148.15 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,348.96 / $4,073.80
| Facility | | $575.44 | $1,348.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $3,090.30
| Professional | | $1,071.52 | $1,445.44 | $3,090.30 |