- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.10 / $1,095.10 / $1,095.10
| Facility | | $1,095.10 | $1,095.10 | $1,095.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.52 / $1,034.52 / $1,095.10
| Professional | | $1,034.52 | $1,034.52 | $1,095.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.37 / $1,664.01 / $1,705.40
| Professional | | $1,407.37 | $1,664.01 | $1,705.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.13 / $1,743.39 / $2,192.17
| Professional | | $1,726.13 | $1,743.39 | $2,192.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.23 / $1,095.10 / $6,933.23
| Facility | | $441.23 | $1,095.10 | $6,933.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.66 / $736.67 / $1,199.31
| Professional | | $599.66 | $736.67 | $1,199.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.36 / $663.55 / $1,199.31
| Professional | | $442.36 | $663.55 | $1,199.31 |