- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $7,762.47
| Facility | | $1,202.26 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $3,548.13
| Professional | | $1,174.90 | $1,230.27 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,772.37 / $16,218.10
| Professional | | $1,348.96 | $9,772.37 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $3,235.94
| Professional | | $1,174.90 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $2,511.89
| Professional | | $1,047.13 | $1,122.02 | $2,511.89 |
- 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
- $1,000.00 / $1,412.54 / $2,818.38
| Professional | | $1,000.00 | $1,412.54 | $2,818.38 |