- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,081.54 / $1,081.54 / $1,400.00
| Facility | | $1,081.54 | $1,081.54 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.68 / $1,140.28 / $1,298.66
| Professional | | $1,014.68 | $1,140.28 | $1,298.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.59 / $1,350.22 / $1,471.08
| Facility | | $1,216.59 | $1,350.22 | $1,471.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.63 / $1,307.63 / $1,307.63
| Professional | | $1,307.63 | $1,307.63 | $1,307.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.96 / $1,301.96 / $1,301.96
| Facility | | $1,301.96 | $1,301.96 | $1,301.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.58 / $1,634.54 / $6,992.32
| Professional | | $1,112.58 | $1,634.54 | $6,992.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.98 / $1,342.60 / $2,027.02
| Professional | | $933.98 | $1,342.60 | $2,027.02 |