- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.03 / $1,258.03 / $1,586.34
| Facility | | $1,258.03 | $1,258.03 | $1,586.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.80 / $466.11 / $2,606.64
| Professional | | $286.80 | $466.11 | $2,606.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.91 / $1,193.91 / $1,515.69
| Professional | | $1,193.91 | $1,193.91 | $1,515.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.45 / $2,606.64 / $3,649.30
| Facility | | $527.45 | $2,606.64 | $3,649.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.88 / $2,734.20 / $3,708.82
| Professional | | $1,052.88 | $2,734.20 | $3,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.10 / $2,080.00 / $2,630.00
| Professional | | $1,367.10 | $2,080.00 | $2,630.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.45 / $2,606.64 / $3,649.30
| Facility | | $527.45 | $2,606.64 | $3,649.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.62 / $1,785.00 / $2,781.90
| Professional | | $822.62 | $1,785.00 | $2,781.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.52 / $1,212.54 / $3,387.66
| Professional | | $1,177.52 | $1,212.54 | $3,387.66 |