- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,467.37 / $8,511.38
| Facility | | $1,659.59 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,754.23
| Professional | | $1,318.26 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $2,691.53 / $9,772.37
| Facility | | $416.87 | $2,691.53 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $2,570.40
| Professional | | $199.53 | $199.53 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,890.45 / $8,709.64
| Facility | | $1,318.26 | $3,890.45 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,454.71 / $4,897.79
| Professional | | $1,000.00 | $2,454.71 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $2,454.71
| Facility | | $1,230.27 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,454.71
| Professional | | $851.14 | $1,230.27 | $2,454.71 |