- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,669.30 / $1,669.30 / $1,669.30
| Facility | | $1,669.30 | $1,669.30 | $1,669.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.91 / $1,552.07 / $1,669.30
| Professional | | $1,380.91 | $1,552.07 | $1,669.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.29 / $2,536.48 / $2,599.59
| Professional | | $2,145.29 | $2,536.48 | $2,599.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.75 / $2,615.65 / $3,288.98
| Professional | | $2,589.75 | $2,615.65 | $3,288.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.29 / $1,669.30 / $11,140.65
| Facility | | $1,019.29 | $1,669.30 | $11,140.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.07 / $1,144.66 / $1,828.13
| Professional | | $914.07 | $1,144.66 | $1,828.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.18 / $1,144.66 / $1,828.13
| Professional | | $695.18 | $1,144.66 | $1,828.13 |