- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,079.46
| Facility | | $1,698.24 | $4,073.80 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,148.15 / $3,235.94
| Professional | | $1,023.29 | $1,148.15 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,570.40 / $6,456.54
| Professional | | $1,230.27 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,884.03
| Professional | | $1,047.13 | $1,348.96 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $2,238.72
| Professional | | $933.25 | $1,000.00 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,454.40 / $26,915.35
| Facility | | $3,311.31 | $14,454.40 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,754.23
| Professional | | $891.25 | $1,258.93 | $2,754.23 |