- 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
- $1,659.59 / $1,905.46 / $3,801.89
| Professional | | $1,659.59 | $1,905.46 | $3,801.89 |
- 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
- $1,905.46 / $2,511.89 / $3,235.94
| Professional | | $1,905.46 | $2,511.89 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,137.96 / $6,025.60
| Facility | | $1,000.00 | $2,137.96 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $13,489.63
| Professional | | $1,584.89 | $2,137.96 | $13,489.63 |
- 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
- $1,513.56 / $1,905.46 / $2,570.40
| Professional | | $1,513.56 | $1,905.46 | $2,570.40 |