- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.96 / $1,202.77 / $1,876.32
| Facility | | $1,127.96 | $1,202.77 | $1,876.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $1,012.86 / $1,503.46
| Professional | | $850.00 | $1,012.86 | $1,503.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.67 / $2,089.33 / $3,172.14
| Facility | | $1,529.67 | $2,089.33 | $3,172.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.77 / $1,266.07 / $1,354.69
| Professional | | $1,202.77 | $1,266.07 | $1,354.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.97 / $1,542.97 / $1,928.71
| Professional | | $1,542.97 | $1,542.97 | $1,928.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.77 / $1,202.77 / $2,210.09
| Facility | | $1,202.77 | $1,202.77 | $2,210.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.77 / $1,215.43 / $1,519.28
| Professional | | $1,202.77 | $1,215.43 | $1,519.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $759.64 / $1,266.07
| Professional | | $531.75 | $759.64 | $1,266.07 |