- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.65 / $1,374.65 / $1,374.65
| Facility | | $1,374.65 | $1,374.65 | $1,374.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.65 / $1,981.98 / $1,981.98
| Professional | | $1,374.65 | $1,981.98 | $1,981.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.61 / $2,088.76 / $2,140.71
| Professional | | $1,766.61 | $2,088.76 | $2,140.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.13 / $2,770.56 / $3,483.77
| Professional | | $2,743.13 | $2,770.56 | $3,483.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.34 / $1,751.86 / $9,406.52
| Facility | | $791.34 | $1,751.86 | $9,406.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.73 / $1,328.07 / $1,528.03
| Professional | | $752.73 | $1,328.07 | $1,528.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.25 / $983.75 / $1,505.45
| Professional | | $590.25 | $983.75 | $1,505.45 |