- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,818.38 / $5,623.41
| Facility | | $1,479.11 | $2,818.38 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,819.70
| Professional | | $1,000.00 | $1,258.93 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,754.23 / $3,467.37
| Facility | | $1,380.38 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,041.74
| Facility | | $1,202.26 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $7,585.78
| Professional | | $630.96 | $912.01 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,513.56 / $1,819.70
| Facility | | $630.96 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $1,995.26
| Professional | | $630.96 | $912.01 | $1,995.26 |