- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.34 / $3,750.63 / $8,074.63
| Facility | | $1,416.34 | $3,750.63 | $8,074.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.53 / $1,490.25 / $2,329.38
| Professional | | $1,340.53 | $1,490.25 | $2,329.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,299.00 / $10,705.54 / $20,791.37
| Facility | | $5,299.00 | $10,705.54 | $20,791.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.17 / $1,842.37 / $2,792.59
| Professional | | $1,359.17 | $1,842.37 | $2,792.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,570.81 / $1,570.81 / $2,163.67
| Facility | | $1,570.81 | $1,570.81 | $2,163.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.42 / $2,065.73 / $3,445.40
| Professional | | $1,410.42 | $2,065.73 | $3,445.40 |
- 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
- $1,385.04 / $1,927.13 / $3,260.18
| Professional | | $1,385.04 | $1,927.13 | $3,260.18 |