- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,733.52 / $1,733.52 / $1,733.52
| Facility | | $1,733.52 | $1,733.52 | $1,733.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,643.85 / $1,868.01
| Professional | | $1,494.41 | $1,643.85 | $1,868.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,741.05 / $2,114.00 / $2,431.10
| Facility | | $1,741.05 | $2,114.00 | $2,431.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $1,994.56 / $2,180.14
| Professional | | $60.00 | $1,994.56 | $2,180.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.47 / $1,643.85 / $1,643.85
| Professional | | $1,479.47 | $1,643.85 | $1,643.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |