- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.51 / $1,166.51 / $1,166.51
| Facility | | $1,166.51 | $1,166.51 | $1,166.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.51 / $1,166.51 / $1,315.32
| Professional | | $1,166.51 | $1,166.51 | $1,315.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,546.29 / $2,973.64 / $4,163.09
| Facility | | $1,546.29 | $2,973.64 | $4,163.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.53 / $1,665.24 / $2,505.48
| Professional | | $1,461.53 | $1,665.24 | $2,505.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.19 / $1,606.19 / $2,714.98
| Facility | | $1,606.19 | $1,606.19 | $2,714.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.52 / $1,606.19 / $11,379.30
| Professional | | $1,172.52 | $1,606.19 | $11,379.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.63 / $1,455.07 / $1,978.01
| Professional | | $1,175.63 | $1,455.07 | $1,978.01 |