- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,405.48 / $1,405.48 / $1,405.48
| Facility | | $1,405.48 | $1,405.48 | $1,405.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.27 / $1,342.27 / $1,405.48
| Professional | | $1,342.27 | $1,342.27 | $1,405.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.23 / $2,135.60 / $2,188.73
| Professional | | $1,806.23 | $2,135.60 | $2,188.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.50 / $2,261.90 / $2,844.17
| Professional | | $2,239.50 | $2,261.90 | $2,844.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.52 / $1,405.48 / $9,986.98
| Facility | | $896.52 | $1,405.48 | $9,986.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.61 / $963.76 / $1,606.26
| Professional | | $769.61 | $963.76 | $1,606.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.50 / $963.76 / $1,606.26
| Professional | | $642.50 | $963.76 | $1,606.26 |