- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,290.87
| Facility | | $1,023.29 | $1,023.29 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,584.89
| Professional | | $870.96 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,348.96
| Facility | | $1,096.48 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,290.87
| Facility | | $1,737.80 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $5,754.40
| Professional | | $977.24 | $1,479.11 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $18,620.87
| Facility | | $2,454.71 | $2,454.71 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,659.59
| Professional | | $794.33 | $1,071.52 | $1,659.59 |