- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,685.11 / $1,685.11 / $1,685.11
| Facility | | $1,685.11 | $1,685.11 | $1,685.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.15 / $848.15 / $848.15
| Professional | | $848.15 | $848.15 | $848.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.30 / $1,505.37 / $2,071.92
| Professional | | $1,204.30 | $1,505.37 | $2,071.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $911.31 / $1,381.46 / $2,733.93
| Facility | | $911.31 | $1,381.46 | $2,733.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.62 / $1,793.02 / $8,640.00
| Professional | | $892.62 | $1,793.02 | $8,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.62 / $1,585.38 / $1,848.24
| Professional | | $892.62 | $1,585.38 | $1,848.24 |