- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.65 / $1,541.65 / $1,541.65
| Facility | | $1,541.65 | $1,541.65 | $1,541.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,541.65 / $1,541.65
| Professional | | $1,427.45 | $1,541.65 | $1,541.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,346.65 / $1,427.45
| Facility | | $1,346.65 | $1,346.65 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,480.39 / $1,554.41 / $2,283.92
| Facility | | $1,480.39 | $1,554.41 | $2,283.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.27 / $1,370.73 / $6,612.00
| Professional | | $1,317.27 | $1,370.73 | $6,612.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,288.69 / $2,288.69 / $2,288.69
| Facility | | $2,288.69 | $2,288.69 | $2,288.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.08 / $1,427.45 / $1,574.05
| Professional | | $1,356.08 | $1,427.45 | $1,574.05 |