- 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
- $2,290.87 / $2,570.40 / $6,309.57
| Professional | | $2,290.87 | $2,570.40 | $6,309.57 |
- 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
- $2,630.27 / $3,467.37 / $4,466.84
| Professional | | $2,630.27 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $6,025.60
| Facility | | $1,000.00 | $2,884.03 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $18,620.87
| Professional | | $2,187.76 | $3,019.95 | $18,620.87 |
- 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
- $2,089.30 / $2,630.27 / $3,548.13
| Professional | | $2,089.30 | $2,630.27 | $3,548.13 |