- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,538.85 / $1,538.85 / $3,957.03
| Facility | | $1,538.85 | $1,538.85 | $3,957.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.85 / $1,538.85 / $2,066.44
| Professional | | $1,538.85 | $1,538.85 | $2,066.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,309.07 / $4,429.68 / $4,946.29
| Professional | | $3,309.07 | $4,429.68 | $4,946.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.91 / $2,525.91 / $3,708.15
| Professional | | $2,525.91 | $2,525.91 | $3,708.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,319.01 / $1,670.75 / $3,957.03
| Facility | | $1,319.01 | $1,670.75 | $3,957.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.16 / $2,638.02 / $4,396.70
| Professional | | $1,121.16 | $2,638.02 | $4,396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $2,242.32 / $3,737.20
| Professional | | $923.31 | $2,242.32 | $3,737.20 |