- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.21 / $1,015.21 / $1,015.21
| Facility | | $1,015.21 | $1,015.21 | $1,015.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.39 / $1,385.84 / $5,154.93
| Professional | | $982.39 | $1,385.84 | $5,154.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,022.07 / $1,022.07
| Facility | | $1,022.07 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $1,022.07 / $1,022.07
| Professional | | $868.76 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.24 / $1,840.31 / $2,760.46
| Professional | | $1,472.24 | $1,840.31 | $2,760.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,198.01 / $1,198.01
| Facility | | $1,022.07 | $1,198.01 | $1,198.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $1,022.07 / $2,093.73
| Professional | | $868.76 | $1,022.07 | $2,093.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.48 / $934.12 / $1,229.49
| Professional | | $754.48 | $934.12 | $1,229.49 |