- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,630.27 / $6,606.93
| Facility | | $1,230.27 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,905.46
| Professional | | $1,000.00 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,584.89
| Professional | | $1,023.29 | $1,380.38 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,479.11 / $6,165.95
| Facility | | $489.78 | $1,479.11 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $7,943.28
| Professional | | $933.25 | $1,258.93 | $7,943.28 |
- 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
- $891.25 / $1,148.15 / $1,698.24
| Professional | | $891.25 | $1,148.15 | $1,698.24 |