- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.86 / $1,444.86 / $1,444.86
| Facility | | $1,444.86 | $1,444.86 | $1,444.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.12 / $1,444.86 / $1,554.02
| Professional | | $1,432.12 | $1,444.86 | $1,554.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,972.93 / $3,977.86 / $5,156.47
| Facility | | $1,972.93 | $3,977.86 | $5,156.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.26 / $2,124.69 / $3,642.32
| Professional | | $1,915.26 | $2,124.69 | $3,642.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $3,556.96
| Facility | | $1,952.91 | $1,952.91 | $3,556.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,952.91 / $14,478.75
| Professional | | $1,425.62 | $1,952.91 | $14,478.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.01 / $1,968.81 / $2,461.01
| Professional | | $1,470.01 | $1,968.81 | $2,461.01 |