- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,398.24 / $1,398.24 / $1,398.24
| Facility | | $1,398.24 | $1,398.24 | $1,398.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.29 / $1,437.93 / $1,437.93
| Professional | | $1,269.29 | $1,437.93 | $1,437.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.93 / $2,124.61 / $2,177.46
| Professional | | $1,796.93 | $2,124.61 | $2,177.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.13 / $2,010.03 / $2,527.46
| Professional | | $1,990.13 | $2,010.03 | $2,527.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.61 / $1,398.24 / $7,578.14
| Facility | | $803.61 | $1,398.24 | $7,578.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.72 / $1,078.64 / $1,531.28
| Professional | | $713.72 | $1,078.64 | $1,531.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.04 / $765.64 / $1,531.28
| Professional | | $563.04 | $765.64 | $1,531.28 |