- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Facility | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,067.11 / $1,092.83
| Professional | | $1,028.55 | $1,067.11 | $1,092.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,048.61 / $3,699.63 / $4,977.18
| Facility | | $3,048.61 | $3,699.63 | $4,977.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.41 / $1,071.41 / $1,071.41
| Professional | | $1,071.41 | $1,071.41 | $1,071.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Facility | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,273.16
| Professional | | $1,092.83 | $1,092.83 | $1,273.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.70 / $1,071.41 / $1,178.55
| Professional | | $910.70 | $1,071.41 | $1,178.55 |