- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $2,454.71
| Facility | | $1,380.38 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $2,344.23
| Professional | | $1,230.27 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $5,495.41
| Facility | | $173.78 | $173.78 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $3,388.44
| Professional | | $1,318.26 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,570.40
| Facility | | $1,778.28 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $4,570.88
| Professional | | $1,513.56 | $1,778.28 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $1,000.00 / $1,995.26
| Facility | | $120.23 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,290.87
| Professional | | $1,000.00 | $1,412.54 | $2,290.87 |