- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $7,762.47
| Facility | | $1,548.82 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $3,890.45
| Professional | | $1,000.00 | $1,548.82 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,445.44 / $13,803.84
| Professional | | $537.03 | $1,445.44 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $3,388.44
| Professional | | $1,258.93 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,380.38 / $2,951.21
| Professional | | $1,318.26 | $1,380.38 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $3,388.44
| Professional | | $1,174.90 | $1,659.59 | $3,388.44 |