- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,344.23 / $4,897.79
| Facility | | $1,071.52 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $1,778.28
| Professional | | $891.25 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,054.61 / $26,302.68
| Facility | | $9,549.93 | $19,054.61 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $1,995.26
| Professional | | $870.96 | $1,258.93 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $954.99 / $1,071.52
| Facility | | $912.01 | $954.99 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $2,089.30
| Professional | | $912.01 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $1,778.28
| Professional | | $851.14 | $1,096.48 | $1,778.28 |