- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $3,467.37
| Professional | | $1,513.56 | $1,737.80 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $5,754.40 / $5,754.40
| Facility | | $891.25 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $2,951.21
| Professional | | $1,737.80 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,041.74 / $6,025.60
| Facility | | $1,000.00 | $2,041.74 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $12,302.69
| Professional | | $1,445.44 | $1,949.84 | $12,302.69 |
- 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
- $1,380.38 / $1,737.80 / $2,344.23
| Professional | | $1,380.38 | $1,737.80 | $2,344.23 |