- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,502.47 / $2,983.50 / $7,780.50
| Facility | | $1,502.47 | $2,983.50 | $7,780.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.08 / $1,456.65 / $1,491.75
| Professional | | $1,167.08 | $1,456.65 | $1,491.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $893.30 / $3,392.48 / $5,374.17
| Facility | | $893.30 | $3,392.48 | $5,374.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.45 / $1,642.84 / $7,957.51
| Professional | | $1,129.45 | $1,642.84 | $7,957.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.34 / $2,737.80 / $4,905.22
| Facility | | $1,019.34 | $2,737.80 | $4,905.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.50 / $1,950.00 / $3,393.00
| Facility | | $1,306.50 | $1,950.00 | $3,393.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $9,711.00
| Professional | | $737.10 | $737.10 | $9,711.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $1,053.00
| Professional | | $737.10 | $737.10 | $1,053.00 |