- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.13 / $2,703.97 / $12,574.60
| Facility | | $1,165.13 | $2,703.97 | $12,574.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.13 / $1,648.76 / $1,868.60
| Professional | | $1,165.13 | $1,648.76 | $1,868.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,148.89 / $3,247.66 / $6,921.96
| Facility | | $2,148.89 | $3,247.66 | $6,921.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.85 / $2,879.84 / $4,005.39
| Professional | | $1,538.85 | $2,879.84 | $4,005.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,400.00 / $8,702.00
| Facility | | $1,400.00 | $1,400.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.29 / $1,319.01 / $2,242.32
| Professional | | $912.29 | $1,319.01 | $2,242.32 |