- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.09 / $1,201.09 / $2,265.26
| Facility | | $1,201.09 | $1,201.09 | $2,265.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.05 / $1,201.09 / $2,155.78
| Professional | | $1,048.05 | $1,201.09 | $2,155.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.31 / $2,011.80 / $3,750.95
| Professional | | $1,264.31 | $2,011.80 | $3,750.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.00 / $2,000.00 / $2,596.63
| Professional | | $1,050.00 | $2,000.00 | $2,596.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.78 / $1,573.52 / $2,177.66
| Professional | | $1,159.78 | $1,573.52 | $2,177.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.00 / $7,273.00 / $10,536.00
| Facility | | $1,846.00 | $7,273.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.57 / $1,775.84 / $3,084.53
| Professional | | $1,004.57 | $1,775.84 | $3,084.53 |