- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,290.87
| Professional | | $1,122.02 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $1,905.46
| Professional | | $1,230.27 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,659.59 / $6,165.95
| Facility | | $489.78 | $1,659.59 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $9,549.93
| Professional | | $1,071.52 | $1,412.54 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,862.09
| Professional | | $1,000.00 | $1,288.25 | $1,862.09 |