- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.08 / $1,584.08 / $1,584.08
| Facility | | $1,584.08 | $1,584.08 | $1,584.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.90 / $1,102.83 / $1,764.54
| Professional | | $555.90 | $1,102.83 | $1,764.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,299.64 / $1,417.98 / $1,504.04
| Facility | | $1,299.64 | $1,417.98 | $1,504.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.46 / $1,407.46 / $1,407.46
| Professional | | $1,407.46 | $1,407.46 | $1,407.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.72 / $1,232.72 / $1,232.72
| Facility | | $1,232.72 | $1,232.72 | $1,232.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.89 / $1,232.72 / $2,761.41
| Professional | | $899.89 | $1,232.72 | $2,761.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.90 / $1,697.81 / $9,329.16
| Facility | | $555.90 | $1,697.81 | $9,329.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.05 / $1,153.27 / $2,691.39
| Professional | | $574.05 | $1,153.27 | $2,691.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.66 / $1,051.00 / $1,407.61
| Professional | | $700.66 | $1,051.00 | $1,407.61 |