- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $14,125.38
| Facility | | $1,023.29 | $1,258.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,288.25
| Professional | | $1,202.26 | $1,258.93 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $275.42 / $512.86
| Facility | | $144.54 | $275.42 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,000.00 / $1,621.81
| Professional | | $125.89 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $1,288.25 / $1,288.25
| Professional | | $186.21 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $2,137.96
| Facility | | $1,096.48 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,122.02 / $1,258.93
| Professional | | $125.89 | $1,122.02 | $1,258.93 |