- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.66 / $3,206.66 / $3,206.66
| Facility | | $3,206.66 | $3,206.66 | $3,206.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.06 / $1,189.50 / $1,189.50
| Professional | | $979.06 | $1,189.50 | $1,189.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.21 / $1,326.75 / $2,038.34
| Professional | | $1,025.21 | $1,326.75 | $2,038.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.00 / $982.00 / $1,110.75
| Facility | | $982.00 | $982.00 | $1,110.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.90 / $1,303.31 / $2,162.04
| Professional | | $847.90 | $1,303.31 | $2,162.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.72 / $1,424.07 / $2,228.42
| Professional | | $1,105.72 | $1,424.07 | $2,228.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.66 / $3,206.66 / $3,206.66
| Facility | | $3,206.66 | $3,206.66 | $3,206.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.06 / $1,189.50 / $2,382.35
| Professional | | $979.06 | $1,189.50 | $2,382.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.13 / $1,268.47 / $2,072.23
| Professional | | $902.13 | $1,268.47 | $2,072.23 |