- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,311.31 / $6,760.83
| Facility | | $1,258.93 | $3,311.31 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,570.40
| Professional | | $1,000.00 | $1,288.25 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $3,981.07 / $13,489.63
| Facility | | $117.49 | $3,981.07 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,862.09 / $5,011.87
| Professional | | $645.65 | $1,862.09 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,905.46 / $7,762.47
| Facility | | $562.34 | $1,905.46 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $2,290.87 / $6,165.95
| Professional | | $537.03 | $2,290.87 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,754.23 / $6,165.95
| Facility | | $1,412.54 | $2,754.23 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $5,623.41
| Professional | | $2,089.30 | $2,884.03 | $5,623.41 |