- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,160.26 / $1,160.26 / $1,160.26
| Facility | | $1,160.26 | $1,160.26 | $1,160.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.26 / $1,781.01 / $1,781.01
| Professional | | $1,160.26 | $1,781.01 | $1,781.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.10 / $1,763.00 / $1,806.86
| Professional | | $1,491.10 | $1,763.00 | $1,806.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.25 / $2,489.90 / $3,130.87
| Professional | | $2,465.25 | $2,489.90 | $3,130.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $786.53 / $1,574.29 / $8,461.77
| Facility | | $786.53 | $1,574.29 | $8,461.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.33 / $1,193.41 / $1,326.01
| Professional | | $635.33 | $1,193.41 | $1,326.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.95 / $1,270.65 / $2,636.66
| Professional | | $622.95 | $1,270.65 | $2,636.66 |