- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,073.80 / $7,762.47
| Facility | | $1,174.90 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,174.90 / $2,951.21
| Professional | | $1,122.02 | $1,174.90 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,818.38 / $6,456.54
| Professional | | $1,202.26 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,951.21
| Professional | | $1,071.52 | $1,513.56 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,398.83 / $2,630.27
| Professional | | $1,202.26 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $9,549.93 / $26,302.68
| Facility | | $2,344.23 | $9,549.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $2,951.21
| Professional | | $1,000.00 | $1,445.44 | $2,951.21 |