- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.11 / $1,081.76 / $1,081.76
| Facility | | $1,001.11 | $1,081.76 | $1,081.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.83 / $981.13 / $1,081.76
| Professional | | $717.83 | $981.13 | $1,081.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.57 / $1,257.85 / $1,257.85
| Professional | | $1,025.57 | $1,257.85 | $1,257.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.14 / $517.14 / $1,312.13
| Professional | | $517.14 | $517.14 | $1,312.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.00 / $1,030.19 / $5,682.97
| Facility | | $347.00 | $1,030.19 | $5,682.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.33 / $684.71 / $1,402.84
| Professional | | $358.33 | $684.71 | $1,402.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.33 / $627.07 / $820.57
| Professional | | $358.33 | $627.07 | $820.57 |