- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.91 / $1,075.91 / $2,766.64
| Facility | | $1,075.91 | $1,075.91 | $2,766.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.91 / $1,075.91 / $1,444.80
| Professional | | $1,075.91 | $1,075.91 | $1,444.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.60 / $3,097.10 / $3,458.30
| Professional | | $2,313.60 | $3,097.10 | $3,458.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.40 / $1,766.40 / $2,593.16
| Professional | | $1,766.40 | $1,766.40 | $2,593.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $922.21 / $1,168.14 / $2,766.64
| Facility | | $922.21 | $1,168.14 | $2,766.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.88 / $1,844.42 / $3,074.04
| Professional | | $783.88 | $1,844.42 | $3,074.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.54 / $1,567.76 / $2,228.67
| Professional | | $645.54 | $1,567.76 | $2,228.67 |