- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.11 / $1,041.11 / $1,041.11
| Facility | | $1,041.11 | $1,041.11 | $1,041.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.54 / $996.41 / $1,041.11
| Professional | | $970.54 | $996.41 | $1,041.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,349.30 / $2,720.56 / $3,526.65
| Facility | | $1,349.30 | $2,720.56 | $3,526.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.90 / $1,453.10 / $2,491.02
| Professional | | $1,309.90 | $1,453.10 | $2,491.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $2,432.64
| Facility | | $1,335.63 | $1,335.63 | $2,432.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $1,335.63 / $9,902.29
| Professional | | $975.01 | $1,335.63 | $9,902.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.24 / $1,021.58 / $1,675.63
| Professional | | $771.24 | $1,021.58 | $1,675.63 |