- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.30 / $1,284.30 / $1,634.37
| Facility | | $1,284.30 | $1,284.30 | $1,634.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.01 / $1,506.80 / $1,640.86
| Professional | | $1,193.01 | $1,506.80 | $1,640.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,752.09 / $3,083.76 / $4,037.04
| Professional | | $2,752.09 | $3,083.76 | $4,037.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.97 / $3,111.13 / $4,923.10
| Professional | | $1,772.97 | $3,111.13 | $4,923.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.30 / $2,046.89 / $2,717.68
| Facility | | $1,284.30 | $2,046.89 | $2,717.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.87 / $3,257.03 / $8,957.68
| Professional | | $1,669.87 | $3,257.03 | $8,957.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.87 / $3,076.08 / $3,618.92
| Professional | | $1,669.87 | $3,076.08 | $3,618.92 |