- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,464.10 / $2,907.31 / $7,581.80
| Facility | | $1,464.10 | $2,907.31 | $7,581.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.63 / $1,577.17 / $1,615.17
| Professional | | $1,263.63 | $1,577.17 | $1,615.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $864.78 / $3,284.18 / $5,202.60
| Facility | | $864.78 | $3,284.18 | $5,202.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.10 / $1,520.16 / $7,363.28
| Professional | | $1,045.10 | $1,520.16 | $7,363.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.08 / $1,319.58 / $3,470.72
| Facility | | $1,043.08 | $1,319.58 | $3,470.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.13 / $1,900.20 / $3,728.13
| Facility | | $1,273.13 | $1,900.20 | $3,728.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.08 / $798.08 / $9,463.00
| Professional | | $798.08 | $798.08 | $9,463.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.08 / $798.08 / $1,140.11
| Professional | | $798.08 | $798.08 | $1,140.11 |