- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.15 / $2,719.46 / $5,471.76
| Facility | | $1,551.15 | $2,719.46 | $5,471.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.00 / $1,587.65 / $2,349.14
| Professional | | $1,075.00 | $1,587.65 | $2,349.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,824.88 / $2,331.42 / $6,314.08
| Facility | | $1,824.88 | $2,331.42 | $6,314.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.17 / $1,140.95 / $2,627.81
| Professional | | $901.17 | $1,140.95 | $2,627.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,688.04 / $3,202.66 / $6,055.64
| Facility | | $1,688.04 | $3,202.66 | $6,055.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.16 / $1,909.11 / $3,616.09
| Professional | | $1,090.16 | $1,909.11 | $3,616.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,824.88 / $1,824.88 / $1,824.88
| Facility | | $1,824.88 | $1,824.88 | $1,824.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.45 / $1,094.93 / $2,485.86
| Professional | | $766.45 | $1,094.93 | $2,485.86 |