- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,709.25 / $1,709.25 / $13,947.50
| Facility | | $1,709.25 | $1,709.25 | $13,947.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.25 / $1,709.25 / $1,709.25
| Professional | | $1,709.25 | $1,709.25 | $1,709.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.20 / $2,051.10 / $2,051.10
| Professional | | $1,823.20 | $2,051.10 | $2,051.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,703.38 / $3,851.51 / $8,284.91
| Facility | | $3,703.38 | $3,851.51 | $8,284.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.02 / $2,645.02 / $2,906.90
| Professional | | $2,645.02 | $2,645.02 | $2,906.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,620.85 / $4,632.52 / $4,632.52
| Professional | | $2,620.85 | $4,632.52 | $4,632.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,367.40 / $2,848.75
| Professional | | $957.18 | $1,367.40 | $2,848.75 |