- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,288.25
| Professional | | $758.58 | $1,000.00 | $1,288.25 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,819.70
| Professional | | $812.83 | $1,071.52 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $2,290.87
| Facility | | $851.14 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $6,760.83
| Professional | | $831.76 | $1,202.26 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,621.81
| Professional | | $831.76 | $1,023.29 | $1,621.81 |