- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.55 / $4,745.00 / $9,696.50
| Facility | | $1,445.55 | $4,745.00 | $9,696.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.20 / $1,223.75 / $1,925.64
| Professional | | $1,106.20 | $1,223.75 | $1,925.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,274.72 / $8,683.04 / $13,628.92
| Facility | | $4,274.72 | $8,683.04 | $13,628.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.73 / $1,520.36 / $2,305.48
| Professional | | $1,122.73 | $1,520.36 | $2,305.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.70 / $1,297.70 / $1,787.19
| Facility | | $1,297.70 | $1,297.70 | $1,787.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.97 / $1,704.70 / $2,713.79
| Professional | | $1,164.97 | $1,704.70 | $2,713.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.00 / $3,325.00 / $8,198.00
| Facility | | $1,403.00 | $3,325.00 | $8,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.03 / $1,546.46 / $2,606.21
| Professional | | $1,134.03 | $1,546.46 | $2,606.21 |