- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,619.03 / $1,619.03 / $1,619.03
| Facility | | $1,619.03 | $1,619.03 | $1,619.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.55 / $1,127.17 / $1,803.47
| Professional | | $622.55 | $1,127.17 | $1,803.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,192.66 / $2,392.31 / $2,537.48
| Facility | | $2,192.66 | $2,392.31 | $2,537.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.55 / $2,374.55 / $2,374.55
| Professional | | $2,374.55 | $2,374.55 | $2,374.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,207.83
| Facility | | $1,207.83 | $1,207.83 | $1,207.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $1,207.83 / $3,135.47
| Professional | | $881.72 | $1,207.83 | $3,135.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.55 / $1,735.25 / $10,094.70
| Facility | | $622.55 | $1,735.25 | $10,094.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.89 / $1,232.83 / $2,750.75
| Professional | | $642.89 | $1,232.83 | $2,750.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.12 / $1,150.94 / $1,529.42
| Professional | | $716.12 | $1,150.94 | $1,529.42 |