- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $2,691.53
| Professional | | $1,348.96 | $1,698.24 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $3,235.94
| Professional | | $1,905.46 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $9,332.54
| Facility | | $1,318.26 | $1,905.46 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,737.80 / $3,981.07
| Professional | | $977.24 | $1,737.80 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,949.84 / $3,388.44
| Facility | | $776.25 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $2,238.72
| Professional | | $977.24 | $1,445.44 | $2,238.72 |