- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.27 / $1,336.27 / $1,336.27
| Facility | | $1,336.27 | $1,336.27 | $1,336.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.66 / $1,336.27 / $1,336.27
| Professional | | $1,249.66 | $1,336.27 | $1,336.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.25 / $1,167.25 / $1,237.28
| Facility | | $1,167.25 | $1,167.25 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.68 / $1,349.96 / $1,979.65
| Facility | | $1,285.68 | $1,349.96 | $1,979.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,190.44 / $5,119.78
| Professional | | $1,055.97 | $1,190.44 | $5,119.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,364.35
| Professional | | $1,055.97 | $1,237.28 | $1,364.35 |