- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.04 / $1,472.04 / $1,472.04
| Facility | | $1,472.04 | $1,472.04 | $1,472.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.04 / $1,780.64 / $1,780.64
| Professional | | $1,472.04 | $1,780.64 | $1,780.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.77 / $2,236.73 / $2,292.38
| Professional | | $1,891.77 | $2,236.73 | $2,292.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.50 / $2,489.15 / $3,129.92
| Professional | | $2,464.50 | $2,489.15 | $3,129.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.52 / $1,591.65 / $9,328.83
| Facility | | $896.52 | $1,591.65 | $9,328.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.05 / $1,307.64 / $1,636.28
| Professional | | $806.05 | $1,307.64 | $1,636.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.16 / $1,307.64 / $1,612.10
| Professional | | $581.16 | $1,307.64 | $1,612.10 |