- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $3,311.31
| Facility | | $1,819.70 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $1,862.09
| Professional | | $1,584.89 | $1,778.28 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $6,606.93
| Facility | | $1,819.70 | $3,548.13 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Professional | | $10,715.19 | $10,715.19 | $10,715.19 |
- 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
- $933.25 / $1,000.00 / $2,754.23
| Professional | | $933.25 | $1,000.00 | $2,754.23 |