- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.54 / $1,554.54 / $1,554.54
| Facility | | $1,554.54 | $1,554.54 | $1,554.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.63 / $1,082.27 / $1,731.64
| Professional | | $513.63 | $1,082.27 | $1,731.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.31 / $1,512.53 / $1,604.32
| Facility | | $1,386.31 | $1,512.53 | $1,604.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.31 / $1,501.31 / $1,501.31
| Professional | | $1,501.31 | $1,501.31 | $1,501.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $1,020.64
| Facility | | $1,020.64 | $1,020.64 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $3,081.56
| Professional | | $745.07 | $1,020.64 | $3,081.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.63 / $1,666.16 / $8,461.77
| Facility | | $513.63 | $1,666.16 | $8,461.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.40 / $1,105.10 / $2,641.24
| Professional | | $530.40 | $1,105.10 | $2,641.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.60 / $1,031.40 / $1,320.62
| Professional | | $687.60 | $1,031.40 | $1,320.62 |