- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.11 / $1,276.11 / $1,276.11
| Facility | | $1,276.11 | $1,276.11 | $1,276.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.11 / $1,458.42 / $1,458.42
| Professional | | $1,276.11 | $1,458.42 | $1,458.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,050.41
| Facility | | $2,050.41 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,373.13
| Professional | | $1,496.80 | $1,496.80 | $3,373.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.83 / $1,786.32 / $15,093.28
| Facility | | $919.83 | $1,786.32 | $15,093.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,882.80 / $3,010.85
| Professional | | $949.88 | $1,882.80 | $3,010.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,421.86 / $2,146.28
| Professional | | $949.88 | $1,421.86 | $2,146.28 |