- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,511.89
| Facility | | $1,174.90 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,584.89
| Professional | | $1,000.00 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $9,549.93
| Facility | | $7,079.46 | $7,079.46 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,513.56
| Professional | | $1,148.15 | $1,148.15 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,862.09 / $2,089.30
| Professional | | $851.14 | $1,862.09 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $2,187.76
| Professional | | $954.99 | $1,202.26 | $2,187.76 |