- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.07 / $1,321.07 / $2,600.00
| Facility | | $1,321.07 | $1,321.07 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.67 / $1,321.07 / $2,315.53
| Professional | | $1,062.67 | $1,321.07 | $2,315.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,344.81 / $1,459.54 / $1,590.19
| Facility | | $1,344.81 | $1,459.54 | $1,590.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.18 / $1,337.91 / $1,581.16
| Professional | | $1,240.18 | $1,337.91 | $1,581.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,467.79 / $1,467.79 / $1,467.79
| Facility | | $1,467.79 | $1,467.79 | $1,467.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.76 / $1,531.29 / $6,694.85
| Professional | | $1,151.76 | $1,531.29 | $6,694.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.14 / $1,285.69 / $1,884.67
| Professional | | $945.14 | $1,285.69 | $1,884.67 |