- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,498.37 / $1,498.37 / $1,498.37
| Facility | | $1,498.37 | $1,498.37 | $1,498.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.37 / $1,706.30 / $1,706.30
| Professional | | $1,498.37 | $1,706.30 | $1,706.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.62 / $2,276.76 / $2,333.39
| Professional | | $1,925.62 | $2,276.76 | $2,333.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.75 / $2,385.37 / $2,999.42
| Professional | | $2,361.75 | $2,385.37 | $2,999.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.63 / $1,594.21 / $9,502.08
| Facility | | $896.63 | $1,594.21 | $9,502.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.47 / $1,361.84 / $1,665.55
| Professional | | $820.47 | $1,361.84 | $1,665.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.26 / $907.89 / $1,640.94
| Professional | | $605.26 | $907.89 | $1,640.94 |