- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,344.23 / $4,897.79
| Facility | | $1,148.15 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $1,949.84
| Professional | | $954.99 | $1,096.48 | $1,949.84 |
- 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
- $954.99 / $1,380.38 / $2,187.76
| Professional | | $954.99 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,047.13 / $1,174.90
| Facility | | $1,000.00 | $1,047.13 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,290.87
| Professional | | $1,000.00 | $1,318.26 | $2,290.87 |
- 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
- $933.25 / $1,174.90 / $1,949.84
| Professional | | $933.25 | $1,174.90 | $1,949.84 |