- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.16 / $1,652.22 / $2,202.96
| Facility | | $1,076.16 | $1,652.22 | $2,202.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.21 / $1,076.16 / $1,228.08
| Professional | | $962.21 | $1,076.16 | $1,228.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.37 / $1,440.00 / $2,332.92
| Professional | | $1,329.37 | $1,440.00 | $2,332.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.83 / $2,444.98 / $3,017.76
| Facility | | $1,743.83 | $2,444.98 | $3,017.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.55 / $1,469.55 / $1,469.55
| Professional | | $1,469.55 | $1,469.55 | $1,469.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.16 / $1,519.28 / $6,013.83
| Facility | | $1,076.16 | $1,519.28 | $6,013.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $759.64 / $6,305.03
| Professional | | $531.75 | $759.64 | $6,305.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $759.64 / $1,431.93
| Professional | | $531.75 | $759.64 | $1,431.93 |