- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.45 / $1,040.45 / $1,040.45
| Facility | | $1,040.45 | $1,040.45 | $1,040.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.91 / $995.77 / $1,305.11
| Professional | | $969.91 | $995.77 | $1,305.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.98 / $2,745.11 / $3,580.58
| Facility | | $1,488.98 | $2,745.11 | $3,580.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.07 / $1,603.52 / $2,748.89
| Professional | | $1,309.07 | $1,603.52 | $2,748.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $2,684.46
| Facility | | $1,544.16 | $1,544.16 | $2,684.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,544.16 / $11,214.79
| Professional | | $1,127.24 | $1,544.16 | $11,214.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.10 / $1,004.74 / $1,682.08
| Professional | | $908.10 | $1,004.74 | $1,682.08 |