- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.23 / $1,154.23 / $1,154.23
| Facility | | $1,154.23 | $1,154.23 | $1,154.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.05 / $1,154.23 / $1,241.43
| Professional | | $1,144.05 | $1,154.23 | $1,241.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,576.06 / $3,177.71 / $4,119.26
| Facility | | $1,576.06 | $3,177.71 | $4,119.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.01 / $1,697.29 / $2,909.64
| Professional | | $1,530.01 | $1,697.29 | $2,909.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.19 / $1,346.19 / $2,841.44
| Facility | | $1,346.19 | $1,346.19 | $2,841.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $1,346.19 / $11,609.07
| Professional | | $982.72 | $1,346.19 | $11,609.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.70 / $1,647.70 / $1,647.70
| Professional | | $1,647.70 | $1,647.70 | $1,647.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.81 / $1,619.04 / $2,201.89
| Professional | | $1,149.81 | $1,619.04 | $2,201.89 |