- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,041.74
| Facility | | $1,023.29 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $3,235.94
| Professional | | $954.99 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $2,187.76
| Professional | | $870.96 | $1,174.90 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,311.31 / $6,025.60
| Facility | | $1,230.27 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,187.76
| Professional | | $1,122.02 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,819.70 / $2,630.27
| Professional | | $977.24 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $2,570.40
| Professional | | $1,258.93 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $3,311.31 / $10,000.00
| Facility | | $575.44 | $3,311.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,398.83
| Professional | | $1,023.29 | $1,380.38 | $2,398.83 |