- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,412.54
| Facility | | $1,148.15 | $1,148.15 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,230.27 / $2,290.87
| Professional | | $1,071.52 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,584.89
| Facility | | $1,288.25 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,089.30 / $2,089.30
| Facility | | $34.67 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $7,585.78
| Professional | | $1,174.90 | $1,698.24 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,137.96
| Professional | | $1,000.00 | $1,380.38 | $2,137.96 |