- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.37 / $1,676.37 / $1,676.37
| Facility | | $1,676.37 | $1,676.37 | $1,676.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.60 / $1,666.60 / $1,676.37
| Professional | | $1,666.60 | $1,666.60 | $1,676.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.36 / $2,547.21 / $2,610.58
| Professional | | $2,154.36 | $2,547.21 | $2,610.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.63 / $2,808.43 / $3,531.39
| Professional | | $2,780.63 | $2,808.43 | $3,531.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.92 / $1,676.37 / $11,712.03
| Facility | | $1,072.92 | $1,676.37 | $11,712.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.94 / $1,149.51 / $1,893.81
| Professional | | $917.94 | $1,149.51 | $1,893.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.52 / $1,261.50 / $2,304.13
| Professional | | $757.52 | $1,261.50 | $2,304.13 |