- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,785.97 / $3,664.32 / $7,087.97
| Facility | | $2,785.97 | $3,664.32 | $7,087.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.22 / $1,277.55 / $1,309.50
| Professional | | $1,195.22 | $1,277.55 | $1,309.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.00 / $1,840.74 / $2,300.92
| Professional | | $1,092.00 | $1,840.74 | $2,300.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.71 / $1,534.65 / $4,226.55
| Facility | | $807.71 | $1,534.65 | $4,226.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.04 / $1,366.74 / $8,640.00
| Professional | | $961.04 | $1,366.74 | $8,640.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.75 / $1,709.22 / $3,104.57
| Facility | | $1,128.75 | $1,709.22 | $3,104.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.07 / $1,957.43 / $2,476.21
| Professional | | $1,274.07 | $1,957.43 | $2,476.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.72 / $620.72 / $620.72
| Facility | | $620.72 | $620.72 | $620.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.04 / $1,372.47 / $1,668.78
| Professional | | $961.04 | $1,372.47 | $1,668.78 |