- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.42 / $3,486.00 / $7,551.30
| Facility | | $1,029.42 | $3,486.00 | $7,551.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.22 / $1,076.22 / $1,076.22
| Professional | | $1,076.22 | $1,076.22 | $1,076.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $641.92 / $898.71 / $6,556.84
| Facility | | $641.92 | $898.71 | $6,556.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.84 / $2,124.11 / $2,544.92
| Professional | | $935.84 | $2,124.11 | $2,544.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.33 / $1,046.36 / $1,046.36
| Professional | | $994.33 | $1,046.36 | $1,046.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.82 / $1,052.82 / $1,754.70
| Facility | | $1,052.82 | $1,052.82 | $1,754.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.43 / $491.32 / $1,832.91
| Professional | | $409.43 | $491.32 | $1,832.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.36 / $1,046.36 / $1,046.36
| Professional | | $1,046.36 | $1,046.36 | $1,046.36 |