- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.43 / $1,318.43 / $1,318.43
| Facility | | $1,318.43 | $1,318.43 | $1,318.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.43 / $1,401.07 / $1,506.78
| Professional | | $1,318.43 | $1,401.07 | $1,506.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $1,823.10
| Facility | | $1,823.10 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,823.10
| Professional | | $1,330.86 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.32 / $1,845.54 / $12,483.67
| Facility | | $751.32 | $1,845.54 | $12,483.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.86 / $1,537.88 / $3,000.81
| Professional | | $775.86 | $1,537.88 | $3,000.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.86 / $1,428.72 / $1,753.09
| Professional | | $775.86 | $1,428.72 | $1,753.09 |