- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,557.30 / $1,557.30 / $1,557.30
| Facility | | $1,557.30 | $1,557.30 | $1,557.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.50 / $1,485.55 / $1,557.30
| Professional | | $1,435.50 | $1,485.55 | $1,557.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.35 / $2,366.30 / $2,425.17
| Professional | | $2,001.35 | $2,366.30 | $2,425.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.13 / $2,076.69 / $2,611.28
| Professional | | $2,056.13 | $2,076.69 | $2,611.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.83 / $1,557.30 / $8,447.07
| Facility | | $908.83 | $1,557.30 | $8,447.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.36 / $1,219.88 / $1,705.47
| Professional | | $737.36 | $1,219.88 | $1,705.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.76 / $1,219.88 / $1,773.59
| Professional | | $636.76 | $1,219.88 | $1,773.59 |