- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.52 / $1,165.52 / $1,165.52
| Facility | | $1,165.52 | $1,165.52 | $1,165.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.65 / $1,579.64 / $2,375.62
| Professional | | $1,515.65 | $1,579.64 | $2,375.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,826.00 / $4,945.58 / $13,227.00
| Facility | | $2,826.00 | $4,945.58 | $13,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.57 / $1,449.21 / $1,670.43
| Professional | | $608.57 | $1,449.21 | $1,670.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.93 / $975.93 / $1,036.24
| Professional | | $975.93 | $975.93 | $1,036.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.06 / $1,148.65 / $2,001.80
| Professional | | $700.06 | $1,148.65 | $2,001.80 |