- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.86 / $1,035.86 / $1,035.86
| Facility | | $1,035.86 | $1,035.86 | $1,035.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.86 / $1,035.86 / $1,035.86
| Professional | | $1,035.86 | $1,035.86 | $1,035.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.00 / $1,089.08 / $1,328.50
| Professional | | $1,042.00 | $1,089.08 | $1,328.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.68 / $1,075.68 / $1,075.68
| Professional | | $1,075.68 | $1,075.68 | $1,075.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.21 / $1,263.21 / $3,857.76
| Professional | | $1,263.21 | $1,263.21 | $3,857.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.36 / $969.54 / $1,474.86
| Professional | | $646.36 | $969.54 | $1,474.86 |