- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.06 / $1,540.06 / $1,540.06
| Facility | | $1,540.06 | $1,540.06 | $1,540.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.13 / $1,498.13 / $1,540.06
| Professional | | $1,498.13 | $1,498.13 | $1,540.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.19 / $2,340.10 / $2,398.31
| Professional | | $1,979.19 | $2,340.10 | $2,398.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,499.75 / $2,524.75 / $3,174.68
| Professional | | $2,499.75 | $2,524.75 | $3,174.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.14 / $1,540.06 / $9,758.87
| Facility | | $942.14 | $1,540.06 | $9,758.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.60 / $1,027.39 / $2,094.98
| Professional | | $799.60 | $1,027.39 | $2,094.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.08 / $977.66 / $1,686.60
| Professional | | $587.08 | $977.66 | $1,686.60 |