- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,290.31 / $5,054.35 / $9,487.99
| Facility | | $1,290.31 | $5,054.35 | $9,487.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.42 / $1,477.88 / $2,417.31
| Professional | | $410.42 | $1,477.88 | $2,417.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.01 / $1,253.01 / $1,476.46
| Professional | | $1,253.01 | $1,253.01 | $1,476.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,113.37 / $2,113.37 / $2,113.37
| Facility | | $2,113.37 | $2,113.37 | $2,113.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.38 / $1,249.85 / $2,254.00
| Professional | | $572.38 | $1,249.85 | $2,254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,710.45 / $3,675.25
| Professional | | $1,506.25 | $1,710.45 | $3,675.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,024.70 / $2,024.70 / $2,113.37
| Facility | | $2,024.70 | $2,024.70 | $2,113.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.02 / $1,583.75 / $3,313.75
| Professional | | $838.02 | $1,583.75 | $3,313.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.50 / $1,181.16 / $6,758.83
| Professional | | $537.50 | $1,181.16 | $6,758.83 |