- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,479.11
| Facility | | $1,230.27 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,548.82
| Professional | | $831.76 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $3,090.30
| Professional | | $1,819.70 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,398.83
| Facility | | $1,230.27 | $1,479.11 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $676.08 / $6,456.54
| Professional | | $575.44 | $676.08 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $3,548.13
| Professional | | $1,862.09 | $3,019.95 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $1,513.56
| Professional | | $549.54 | $676.08 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |