- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.05 / $1,072.05 / $1,072.05
| Facility | | $1,072.05 | $1,072.05 | $1,072.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.43 / $1,026.02 / $1,130.26
| Professional | | $931.43 | $1,026.02 | $1,130.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.82 / $2,593.89 / $3,631.44
| Facility | | $1,348.82 | $2,593.89 | $3,631.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.32 / $1,452.58 / $2,258.27
| Professional | | $1,317.32 | $1,452.58 | $2,258.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $2,477.81
| Facility | | $1,277.46 | $1,277.46 | $2,477.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $1,277.46 / $10,385.27
| Professional | | $932.55 | $1,277.46 | $10,385.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.90 / $1,042.31 / $1,725.42
| Professional | | $786.90 | $1,042.31 | $1,725.42 |