- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $2,754.23
| Facility | | $2,398.83 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $977.24 / $1,000.00
| Professional | | $954.99 | $977.24 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,318.26
| Professional | | $1,071.52 | $1,071.52 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,348.96 / $1,584.89
| Professional | | $151.36 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1,174.90 / $1,862.09
| Facility | | $1.00 | $1,174.90 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $2,041.74
| Professional | | $1,174.90 | $1,174.90 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.20 / $1.20 / $1.20
| Facility | | $1.20 | $1.20 | $1.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,230.27
| Professional | | $1,174.90 | $1,174.90 | $1,230.27 |