- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.72 / $1,301.72 / $1,301.72
| Facility | | $1,301.72 | $1,301.72 | $1,301.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.72 / $1,456.62 / $1,487.68
| Professional | | $1,301.72 | $1,456.62 | $1,487.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $1,769.38
| Facility | | $1,769.38 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $1,769.38
| Professional | | $1,291.65 | $1,769.38 | $1,769.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.11 / $1,822.16 / $12,904.54
| Facility | | $781.11 | $1,822.16 | $12,904.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.62 / $1,598.86 / $3,024.83
| Professional | | $806.62 | $1,598.86 | $3,024.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.62 / $1,410.61 / $1,822.59
| Professional | | $806.62 | $1,410.61 | $1,822.59 |