- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,352.23 / $2,685.15 / $7,002.45
| Facility | | $1,352.23 | $2,685.15 | $7,002.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.08 / $1,316.25 / $1,491.75
| Professional | | $1,167.08 | $1,316.25 | $1,491.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.97 / $3,053.23 / $4,836.74
| Facility | | $803.97 | $3,053.23 | $4,836.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.50 / $1,478.55 / $7,161.74
| Professional | | $1,016.50 | $1,478.55 | $7,161.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $963.39 / $1,218.75 / $3,205.51
| Facility | | $963.39 | $1,218.75 | $3,205.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,175.84 / $1,755.00 / $3,443.34
| Facility | | $1,175.84 | $1,755.00 | $3,443.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $8,739.90
| Professional | | $737.10 | $737.10 | $8,739.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $1,053.00
| Professional | | $737.10 | $737.10 | $1,053.00 |