- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.40 / $1,082.40 / $1,082.40
| Facility | | $1,082.40 | $1,082.40 | $1,082.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.55 / $1,082.40 / $1,914.94
| Professional | | $1,038.55 | $1,082.40 | $1,914.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.92 / $2,186.92 / $2,631.74
| Professional | | $2,186.92 | $2,186.92 | $2,631.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.05 / $1,407.05 / $1,553.49
| Facility | | $1,407.05 | $1,407.05 | $1,553.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,376.83
| Professional | | $1,027.15 | $1,027.15 | $1,376.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.17 / $1,600.27 / $3,434.54
| Facility | | $973.17 | $1,600.27 | $3,434.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.27 / $1,600.27 / $1,600.27
| Professional | | $1,600.27 | $1,600.27 | $1,600.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.77 / $1,477.77 / $1,477.77
| Professional | | $1,477.77 | $1,477.77 | $1,477.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.35 / $1,042.39 / $1,315.12
| Professional | | $727.35 | $1,042.39 | $1,315.12 |