- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,543.03 / $3,955.04
| Facility | | $1,518.41 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.20 / $1,251.29 / $1,417.06
| Professional | | $1,064.20 | $1,251.29 | $1,417.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.23 / $1,426.15 / $2,124.09
| Professional | | $1,212.23 | $1,426.15 | $2,124.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,557.18 / $2,406.77
| Professional | | $300.00 | $1,557.18 | $2,406.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.00 / $1,788.00 / $4,082.00
| Facility | | $1,069.00 | $1,788.00 | $4,082.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.04 / $1,668.29 / $2,304.44
| Professional | | $1,058.04 | $1,668.29 | $2,304.44 |