- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $4,897.79
| Facility | | $1,412.54 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,348.96 / $2,398.83
| Professional | | $1,174.90 | $1,348.96 | $2,398.83 |
- 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
- $1,000.00 / $1,288.25 / $2,137.96
| Professional | | $1,000.00 | $1,288.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,288.25 / $1,445.44
| Facility | | $1,230.27 | $1,288.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,630.27
| Professional | | $1,174.90 | $1,584.89 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,818.38 / $4,265.80
| Facility | | $323.59 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,398.83
| Professional | | $1,148.15 | $1,479.11 | $2,398.83 |