- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,319.04 / $1,319.04 / $1,319.04
| Facility | | $1,319.04 | $1,319.04 | $1,319.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.58 / $1,319.04 / $1,763.87
| Professional | | $776.58 | $1,319.04 | $1,763.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,355.42 / $2,646.56 / $4,805.08
| Facility | | $2,355.42 | $2,646.56 | $4,805.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.07 / $1,250.07 / $1,350.08
| Professional | | $1,250.07 | $1,250.07 | $1,350.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.55 / $1,300.55 / $1,300.55
| Facility | | $1,300.55 | $1,300.55 | $1,300.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $2,701.13
| Professional | | $949.40 | $949.40 | $2,701.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.35 / $1,319.04 / $2,963.24
| Facility | | $670.35 | $1,319.04 | $2,963.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.35 / $670.35 / $670.35
| Professional | | $670.35 | $670.35 | $670.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.46 / $2,944.29 / $4,663.75
| Professional | | $1,719.46 | $2,944.29 | $4,663.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.83 / $1,038.36 / $1,653.46
| Professional | | $942.83 | $1,038.36 | $1,653.46 |