- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.06 / $1,080.06 / $1,080.06
| Facility | | $1,080.06 | $1,080.06 | $1,080.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.06 / $1,234.97 / $1,234.97
| Professional | | $1,080.06 | $1,234.97 | $1,234.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.02 / $1,641.13 / $1,681.96
| Professional | | $1,388.02 | $1,641.13 | $1,681.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.63 / $2,081.23 / $2,616.98
| Professional | | $2,060.63 | $2,081.23 | $2,616.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.66 / $1,234.97 / $7,860.20
| Facility | | $827.66 | $1,234.97 | $7,860.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.41 / $800.64 / $1,234.34
| Professional | | $591.41 | $800.64 | $1,234.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.74 / $740.61 / $1,484.52
| Professional | | $493.74 | $740.61 | $1,484.52 |