- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.43 / $1,411.43 / $1,411.43
| Facility | | $1,411.43 | $1,411.43 | $1,411.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.43 / $1,624.93 / $1,624.93
| Professional | | $1,411.43 | $1,624.93 | $1,624.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.89 / $2,144.66 / $2,198.01
| Professional | | $1,813.89 | $2,144.66 | $2,198.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.88 / $2,271.36 / $2,856.07
| Professional | | $2,248.88 | $2,271.36 | $2,856.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,081.58 / $1,555.50 / $9,310.49
| Facility | | $1,081.58 | $1,555.50 | $9,310.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.87 / $1,451.75 / $1,613.06
| Professional | | $772.87 | $1,451.75 | $1,613.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.22 / $1,451.75 / $2,302.46
| Professional | | $645.22 | $1,451.75 | $2,302.46 |